The Health of the Nation

HC Deb 22 October 1992 vol 212 cc592-662

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Nicholas Baker.]

5.7 pm

The Secretary of State for Health (Mrs. Virginia Bottomley)

This is the first opportunity that the House has had to debate health in detail since the general election. I want to begin with the significance to the national health service—and to the health of the nation—of the outcome of that election.

Before that, however, it is a pleasant duty for me to welcome the hon. Member for Sheffield, Brightside (Mr. Blunkett) to his place on the Opposition Front Bench. With community care much on our minds, I am sure that the House will benefit from the experience of local government that he will bring to our debates. If there is one regret about the hon. Gentleman's appointment, it is that our deliberations will in future be without the often unique insights of his predecessor. We remember the predictions of the hon. Member for Livingston (Mr. Cook). He predicted that the targets under the GP contract were "so heroic" that no GP would ever reach them.

Madam Speaker

Order. I am sorry to interrupt the right hon. Lady. It was remiss of me not to say at the outset that I have had so many requests from hon. Members wishing to speak today in this debate that I have had to limit speeches to 10 minutes between 7 pm and 9 pm. I am sorry to have interrupted the right hon. Lady, but I thought that the House should be told right away of the depth of interest in the debate.

Mrs. Bottomley

I am delighted to hear that there is such an interest in this debate. I was only worried that you, Madam Speaker, were going to try to confine my remarks to 10 minutes, which would have been difficult.

I was referring nostalgically to the predecessor of the hon. Member for Brightside who predicted that the targets were "so heroic" that no GP would ever reach them. He once likened the idea of an NHS trust to a "bicycle with a flat tyre" that would never get anywhere. He predicted that the true test of the trusts would be whether they treated more patients. The GPs are meeting and beating the targets. NHS trusts have become an unstoppable movement, and they are treating more patients. Among the hon. Member's more famous sayings was that the general election would be a referendum on the future of the NHS. I do not think that he predicted the right outcome in that case either.

However, the hon. Member was correct in one important way. The general election was crucial to the future of the national health service. The Labour party fought the election with a socialist plan to turn the clock back 40 years—to the days of central planning, command systems of control, when the Minister was expected to know whenever a bedpan was dropped in a ward. Anyone who knows anything about running a £36 billion organisation knows that such ideas just will not wash. While such policies were being hastily dismantled in Leningrad and Leipzig, they were all the rage in Livingston.

Had it won the general election, the Labour party would presumably be putting those ideas into practice now. One can imagine the resulting chaos and vandalism.

My hon. Friends will be only too aware that 156 trusts would be told to stop innovating on behalf of patients and report to Whitehall immediately. More than 3,000 GP fund holders would have had their budgets snatched away; they would have had no more power to pioneer for patients, and all the efforts of their staff and all the progress, hard work and achievements of reform would have been dumped in a dash for socialism.

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

The Secretary of State will he aware that the trusts are anxious that they should not be responsible to her—they do not like that idea. If there are increasing numbers of trusts and if they continue to use taxpayers' money, will she be kind enough to tell us to whom they should be responsible?

Mrs. Bottomley

The trusts are unequivocally accountable to me, as Secretary of State, and there are effective mechanisms for monitoring their work. They have been singularly successful, they have treated many more patients and they have provided an excellent working environment for their staff. They have achieved much in the NHS, and I am sure that the rest of the service could learn from their record. The hon. Lady's remarks are a sign of what the trusts might have had to face in the miserable event of the Labour party winning the general election.

It is a very different NHS under this Government—it is a good service and an improving service. The Conservative victory in the general election has given new confidence and a reinforced sense of direction. The consensus grows day by day that the health reforms are the right answer to a series of management problems that have built up over 40 years.

Two weeks ago, I announced a further 128 trusts, and more are waiting in the wings. Family doctors are queueing to take control over their own budgets. Health authorities are discovering the immense potential of their new role as commissioners and purchasers of health care. The GP contract is delivering better health care and better health, and public confidence in the health service is growing—[Laughter.] The hon. Member for Brightside may laugh. I wonder whether he knows about the recent survey that showed that 95 per cent. of the patients who had used his local NHS trust were satisfied with the service that they received.

The true significance of these achievements was well summed up recently by the British Medical Journal. Referring to the Government's three White Papers, "Promoting Better Health-, "Working for Patients", and "The Health of the Nation", it said: Taken together, the White Papers are unusual because they represent a continuum in Government policy … as a conceptual feat it can rarely have been equalled in the realm of public administration".

Mr. Hugh Bayley (York)

During the summer I was asked to intervene by one of my constituents whose mother was about to be discharged from a Bristol hospital. Her daughter was told that she could not be discharged until she and her daughter had paid a fee of £600 to Avon ambulance trust. Is that the type of outcome that the right hon. Lady intended when she created trusts? Did she expect me, as a Member of Parliament, to have to phone half a dozen health administrators in Bristol to explain to them that it would be more costly if my constituent blocked a bed in her hospital than if the NHS paid for her ambulance transport to the nursing home to which she was going?

Mrs. Bottomley

Had the hon. Gentleman wanted a serious answer to his question, he would have been in touch with my office with the details. I have consistently and unequivocally been committed to an NHS available to all and free at the point of delivery. The hon. Gentleman can easily give me the details and I will look into the case immediately. I should very much like to know what lies behind the circumstances that he has described. [Interruption.]

Madam Deputy Speaker (Dame Janet Fookes)

Order. The Secretary of State is doing her best to answer, and I do not expect a whole lot of seated interventions.

Mr. Bernie Grant (Tottenham)

Will the right hon. Lady give way?

Mrs. Bottomley

Certainly.

Mr. Grant

I was pleased to hear the Secretary of State say that the NHS trusts are directly responsible to her and that mechanisms have been set up to monitor their progress. Can she tell me, a poor working Member of Parliament who is not quite au fait with bureaucracy, whom I should go to if a mistake has been made in the tendering procedure between the health authority and the trust? Who can rectify that?

Mrs. Bottomley

I should like to know more of the details, but the system is clear. The district health authority places a contract with the NHS trust in which it specifies the quality and nature of the service to be delivered. That never happened in the past. It was never possible to place such contracts or to identify improvements needed in the quality of care that the health authority sought. In the first instance, the hon. Gentleman should therefore go to the district health authority.

It is also clear who has responsibility in the NHS trust. The position of trust chairman has clarified the structure in a new way. It is therefore easier to know what is being provided, what standards are being adhered to and what plans there are for the future.

Mr. Richard Burden (Birmingham, Northfield)

I want to raise a matter that the right hon. Lady knows about. She says that trusts are accountable to her, as Secretary of State. Are regional health authorities also so accountable? If so, why are she and her Department colluding in the suppression of a report commissioned by the West Midlands regional health authority into the causes of a multi-million pound cash crisis in South Birmingham health authority which is threatening to close two hospitals, to transfer services from a third hospital, to cut community services by about £300,000 and to cut services for the mentally ill by about £200,000? If she believes that public confidence in the trust is so high, why will she not publish this report?

Mrs. Bottomley

Like so many other Labour Members, the hon. Gentleman is trying to denigrate the achievements of the NHS in his area. That is an insult to all the people who work in the NHS. The hon. Gentleman may be aware that I have asked the deputy chairman of the policy board, Sir Roy Griffiths, to advise on some of the systems of the West Midlands and to report to me.

The establishment of the trusts, the fact that health authorities can assess health needs, and the placing of contracts mean that we are in a position to develop a health strategy that we would not have been able to develop without the reforms. As purchasers, health authorities can now respond strategically to the health needs of the populations they serve. Through their contracts with hospitals and other providers, they can write prevention firmly into the structure of the NHS. The GP contract, another key element of the reforms opposed by the Labour party, made health promotion a priority. Among other things, it made a real success of our childhood immunisation programme. The 90 per cent. targets have been exceeded, setting us on course for the 95 per cent. target set out in the White Paper.

When I used to work in the health service when the Labour party was in power, figures of this sort would have been inconceivable and unattainable. Building on an already sound base, the White Paper has set a new target for childhood immunisation—95 per cent. coverage by 1995. I am pleased to be able to report that one NHS region, East Anglia, has already reached that level for all seven immunisations. Three other regions, Oxford, South Western and Wessex, have reached 95 per cent. for all diseases except whooping cough. At the end of last month, we announced that the new HIB vaccine against childhood meningitis has been added to the routine immunisation programme.

Thanks to these changes, which the general election secured, we can now lift our sights about the structural issues which have preoccupied the national health service for over 40 years. Never have we been in a better position to secure the most important founding goal of the national health service: better health for the people of our country.

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

The right hon. Lady said that we have got over the structural difficulties now. She also said that we should not denigrate the health service—we should pay tribute to its work. Would she care to pay tribute to the work of St. Bartholomew's, St. Thomas's, Charing Cross, Middlesex and University College London, and then tell the House why she will make a statement tomorrow suggesting that four of them be closed?

Mrs. Bottomley

I have read with some interest the correspondence between the hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore) and the person I had taken to be the Opposition spokesman on this matter. I am interested to know who it is who speaks most accurately for the situation in London.

Mr. Sedgemore

Will the right hon. Lady pay tribute to those hospitals?

Mrs. Bottomley

I pay a warm tribute to much of the excellence achieved by the health service in London. However, no one who has even half focused on the situation in London could fail to know that for many years we have been over-dominated by institutions and under-provided for in terms of community services. The need for the reform of the health service in London is supported by the British Medical Association, the nurses' organisations and virtually every even half-enlightened Member of Parliament, as well as by the public.

I should like to remind the House, if I have not already done so, that the Labour party opposed every turn and every measure that has made better health a realistic goal. While we were working through the logical progression towards better health, the Labour party shouted, "Go back" at every point. This debate would not have taken place if the Opposition had had their way. The purpose of the Opposition is to exploit the NHS for their party-political aims. The public are heartily sick of them using the health service as a political battering ram.

The new mood is to lose politics and to gain health. The White Paper "The Health of the Nation" has been a handsome investment to that end. The Labour party should come clean and acknowledge that. That White Paper and the strategy it sets out received a warm and enthusiastic welcome. The World Health Organisation described it as a model for other countries to follow. The British Medical Journal said that it was a huge step forward for Britain's health policy". A distinguished former president of the Royal College of Physicians called it a "mighty initiative". Those remarks illustrate how the strategy has captured both the hearts and the minds of everyone concerned with health.

No one should underestimate the significance of the White Paper. It has provided the first-ever coherent strategy in this country for securing real improvements in health and the first-ever national targets for reducing death and disability. It is the first time that we have ever had a Cabinet committee concerned with health. Most important of all, the White Paper has made us one of the first countries to specify action to achieve those targets. Most other strategies simply set targets, but our White Paper is not just an index of destinations; it is the road map as well.

One hundred years ago the average life expectancy was 44 years. Today I am pleased to tell my hon. Friend the Member for Broxbourne (Mrs. Roe) that it is 73 years for men and 79 for women. The step-change a century ago was achieved not by doctors, pharmacists or physicians, but by plumbers. Clean water and better sanitation revolutionised our health prospects. If we want to see a further step-change in the fight against disability and disease today, it will be achieved by prevention and by the strategy that we have set out in the White Paper.

The five priority areas, the 25 national targets and the action to meet them are of direct relevance to everyone and every group in this country. The areas on which we have focused are the ones where the public want action.

Mr. Anthony Coombs (Wyre Forest)

One item of public health that is not included in those key areas is asthma. My right hon. Friend is aware that I have raised this matter on a number of occasions and she will know that 2.5 million people and 700,000 young people suffer from asthma. It is one of the few preventable diseases for which mortality rates are increasing.

Some work has been done at East Birmingham hospital on the relationship between the increased incidence of asthma and environmental pollution, in particular the effects of greenhouse gases and the depletion of the ozone layer. Can my right hon. Friend tell me whether the Medical Research Council might be persuaded to study the important relationship between environmental pollution and the incidence of that disease?

Mrs. Bottomley

I welcome my hon. Friend's comments on this important problem, which affects a great number of people. Our health strategy must be informed by research and by the ability to specify a target that can be delivered effectively. Asthma is one of those areas where we hope to be able to set a target. A great deal of work is under way through chronic disease management and with GPs. The director of research and development at the NHS has set asthma as a priority area. He will conduct research, much of it with the M RC, to see whether it will be possible to set a target in precisely the area that my hon. Friend has requested.

Ms. Tessa Jowell (Dulwich)

Will the Secretary of State give way?

Mrs. Bottomley

I have given way to many Opposition Members and I should like to proceed and perhaps be more even-handed with some of my hon. Friends.

Targets provide a stimulus for action. They give a yardstick against which we can measure progress and they are an end point at which to aim. They are challenging targets—achievable but tough. Our job now is to see that they are achieved, but we must harness that great reservoir of good will that the White Paper has generated. We must use it so that health promotion becomes a cause to unite us all. Given the incentives and the right information, people will take action, individually or collectively, to improve their own health.

Some people say that it is no business of a Government to dictate how people run their lives. I believe in individual freedom as deeply as those who make that argument. I believe in the freedom to avoid the dangers of excessive alcohol consumption. I believe in the freedom to avoid needless accidents. I believe in the freedom to avoid the causes and consequences of mental illness, but the process must be one of encouragement and education, not coercion. There are some steps that we simply cannot take.

I reject, for example, a coercive approach to immunisation or to those who are HIV positive. That is a dangerous path wholly inimical to the positive and co-operative approach set out in the White Paper. There is an enormous willingness and readiness among individuals to take action to help themselves to a healthier life. We must work with that grain.

The Government's chief medical officer recently said: Increasingly, lifestyle is seen to be a factor of great importance in improving health. Cigarette smoking, excessive alcohol consumption and drug misuse are three areas of particular concern". He went on to emphasise the importance of individual responsibility for health.

Individual responsibility is as important as individual freedom. The individual has a responsibility to his family and to the community. The Government have a duty to educate, encourage and inform. Today, I cannot talk separately about each of the areas in the White Paper, especially in view of the 10-minute rule and the fact that so many hon. Members want to participate in the debate. They are all important, but I should like to identify a number of them.

Earlier I mentioned the impact of mental illness and the toll that it takes. My previous training and work made me particularly conscious of the dreadful impact that that all too often forgotten disease can have on individuals and their families. Mental illness is as common as heart disease and three times as common as cancer. It represents a vast cost to our health service and our economy and it is a tragic cost to individuals and their families. By making mental health one of the key target areas in the White Paper we have sent a strong signal that we are taking it seriously.

Mrs. Alice Mahon (Halifax)

The right hon. Lady will know that, in January, I introduced a Bill about health benefits and making them available to people who receive means-tested benefits. Many people with mental illness live in the community, but they are only able to do so because they have access to the kind of drugs that control their illness. Will the right hon. Lady tell us whether she has considered making the prescriptions for those people free if they are in receipt of any means-tested benefit? Why is there no mention of that in the White Paper? A review of health benefits was set up so long ago that I have almost forgotten when that happened. When will the findings of that review be produced?

Mrs. Bottomley

On prescription charges, a mere one item in five carries a charge. When the Opposition were in power it was a much higher figure, as the hon. Lady will be well aware. There has been great progress in the percentage of prescriptions without a charge. There are benefits—no pensioner and no one on a low income pays the prescription charge. I hope that I can come back to the hon. Member for Halifax (Mrs. Mahon) at a later date about the timing of the review that she mentioned—[HON. MEMBERS: "Answer."] I have answered the hon. Lady clearly. It is free for pensioners and for those on low incomes and only one item in five carries a charge. To me, that is a convincing case.

By making mental health one of the key target areas of the White Paper we have sent a strong signal that it is vital. One of the other challenges facing us is the newest—that of HIV and AIDS. It is a disease for which there is no known cure. Our response must rest on prevention. Our record of response is second to none. It continues to be a model for others, acclaimed both here and abroad.

Our early recognition of the problems, and the actions which followed, may in part explain why we have a lower incidence of AIDS in our population compared to some other parts of the world, including many European countries.

The inclusion of HIV, AIDS and sexual health as a priority area in the health strategy provides a framework for Government, for the health service, for local authorities and for the voluntary sector, to develop policies and services to sustain that achievement.

Mr. Jerry Hayes (Harlow)

In the light of my right hon. Friend's encouraging remarks, will she ignore some of the hysterical comments in the tabloid newspapers and warn young heterosexual people that they are still at risk? Will she continue her excellent campaign of informing people, because many young heterosexuals are dying through ignorance?

Mrs. Bottomley

I thank my hon. Friend for reinforcing the argument so effectively. HIV and AIDS is a disease for which there is no known cure and young people need to know the fatal facts of HIV infection. Above all, they need to know about the high-risk behaviours likely to lead to such infection. We need to continue to develop services for people with HIV, which are rooted in the mainstream of health care.

Smoking remains one of the biggest single causes of preventable disease and premature death in this country. Action to reduce smoking is central to achieving targets in two of the five key areas in the White Paper and we are determined to build on a record of solid achievement. The United Kingdom's record in reducing smoking in recent years is, after the Netherlands, the best in Europe. There has been a fall in smoking from 45 to 30 per cent. Our target is to be the best and to reduce it to 20 per cent.

Like us, the Dutch—who also have a good record—maintain voluntary controls over tobacco advertising. Like us, they are opposed to an EC directive on advertising. We regard that as unnecessary interference from Brussels and unnecessary to the completion of the single market.

I should be more impressed by the arguments if any of the countries urging us to go further on advertising had a record on reducing smoking which was as good as ours. Those who grow tobacco—land many do, with handsome subsidies to the tune of £1 billion under the common agricultural policy—have little to tell us. The majority of those who grow their own tobacco apparently support an advertising ban. I am also reluctant to take lessons on the subject from those countries with nationalised tobacco industries. They all support a ban on advertising. It does not take a great deal to detect the mixed motivation in that.

Mr. David Martin (Portsmouth, South)

Does my right hon. Friend think there are any inconsistencies, as I do, in the treatment of smoking and drinking as regards advertising? When one thinks of the number of passive deaths caused by drinking, and of the deaths and injuries to children and others on the roads, which must equate with the passive effects of smoking, why do not people press strongly to ban drink advertising when they are so keen to ban tobacco advertising?

Mrs. Bottomley

As ever, my hon. Friend has identified an excellent issue. People who believe in banning advertising see it as the beginning of a slippery slope towards a ban on advertising all sorts of items and an ever-growing inhibition on commercial freedom of speech. My hon. Friend is right. We should create the climate of opinion which we achieved so successfully with drinking and driving, when we made it unacceptable. My commitment and crusade is to ensure that young people take smoking as seriously as they take the dangers of drinking and driving. That success was achieved not through an advertising ban or random breath tests, but by changing the culture and reinforcing the seriousness of the message—and in no small measure by the excellent work of my noble Friend, the former Member for Wallasey, Lady Chalker, and of the splendid hon. Member for Eltham (Mr. Bottomley).

On price, I wish that no European country sold cigarettes as cheaply as 41p a packet. Spain supports a ban on advertising, but its cigarettes are one sixth the price that they are here. We shall bring pressure to bear on our neighbours to rectify those deficiencies. That seems to be an area where they should be looking to the lead that we have shown in reducing smoking, and not the other way round.

My predecessor commissioned a study into the impact of advertising on tobacco consumption. I am pleased to inform the House that I have asked for its publication to be speeded up. It will be published next Thursday.

The Health Select Committee is conducting an important investigation into tobacco advertising. I am sure that the House will agree that that is the right time and place to discuss those complex issues in the detail that they demand. I pay tribute to my hon. Friend the Member for Broxbourne and to the members of the Committee for tackling that important subject.

There is no doubt that tobacco advertising can affect consumption or attitudes towards consumption. That is why we maintain one of the most advanced, long-standing, comprehensive and effective systems of voluntary controls over tobacco advertising in Europe. That is why the White Paper undertakes to keep that position under review. I shall tell the Select Committee next week how we can honour that commitment.

Of course, I am aware of the public health arguments. But there are others as well. I know that arguments about freedom mean nothing to the Opposition, but I remind the House that proper consideration has to be given to the principle of commercial freedom of speech, as I told my hon. Friend the Member for Portsmouth, South (Mr. Martin).

We have to proceed cautiously. What we do must be justified in terms of further substantial reductions in smoking, in the context of the existing, tough controls, and weighed against the impact of other measures, such as a further increase in price. Frankly, it is the Labour party's position which is illogical and inconsistent and the reason is that it owes far more to public politics than to public health.

The public health issue is how to achieve the tough targets for reducing smoking that we have set out in the White Paper. We need to tackle that issue—it is the end and not the means—with a sense of proportion and judgment that are wholly lacking from the Labour party's knee-jerk analysis of the problem.

Meeting and beating those targets will require even more dramatic reductions in smoking than we have achieved in recent years. But they will be met and beaten and the White Paper has set out the way forward.

The strategy must involve better public education. I have drawn to the attention of the House a recent survey carried out by the Office of Population Censuses and Surveys in 1990 among secondary school children, which showed that children whose parents both smoked were two and a half times as likely to be regular smokers as those where neither parent smoked.

I have already mentioned price. The evidence is that a 10 per cent. price increase can lead to a 3 to 6 per cent. fall in tobacco consumption. Even the Labour party may be interested to know that the real retail price of tobacco has risen by 43 per cent. It may be less anxious to recognise that between 1974 and 1979 the price increased by under 1 per cent. in real terms. For the first time ever, we have given the commitment at least to maintain the real level of taxes on tobacco products. My right hon. Friend the Chancellor of the Exchequer is in no doubt—the House should be in no doubt—that price is a central factor in affecting smoking behaviour.

I turn to another issue that has been mentioned in mutterings by Labour Members. It is said that we have overlooked health variations. Those who make that assertion either have not read the White Paper or have not grasped the significance of the cross-government approach that it sets out.

Every country has variations in health. Some may be associated with low incomes, but, in contrast, some, like breast cancer, can be linked to increasing affluence. Let us be clear. Since the Government came to power, the health of the whole population has improved. Infant mortality, for example, has now fallen to its lowest ever level. Last year, fewer women died in childbirth than in any previous year. There have been dramatic and welcome reductions across every social class. Similarly, life expectancy has increased across the board. In certain areas—for example, general practitioner deprivation payments, which, as they are part of the new contract, the knee-jerk party, the Labour party, inevitably opposed vehemently—we have taken specific action to improve access to health care and health in the most deprived areas. The White Paper specifically calls for action to address variations in each of the priority areas. We must ensure that the rest do as well as the best.

Locally and nationally, we shall identify the variations that occur in particular health problems in order to concentrate efforts on those at particular risk. Different strategies will be appropriate for different groups. The chief medical officer's recent report highlighted some of the special patterns of health that are experienced particularly by black and ethnic minority communities, such as coronary heart disease, hypertension and mental illness for different groups. Our strategy explicity states: the needs of people from black and ethnic groups must be considered. I have asked my noble Friend the Under-Secretary of State to take special responsibility for following up these particular health issues. She will be holding regular meetings with different groups to ensure that we plan for and analyse what more needs to be done.

Mr. Toby Jessel (Twickenham)

Before my right lion. Friend leaves the subject of priority or key areas, I wish to thank her and my hon. Friend the Member for Bolton, West (Mr. Sackville), the Under-Secretary of State, for the great interest that they have been taking in back pain, which has been identified in the White Paper as one of the next five strongest candidates for key area status. Back pain is a scourge for millions of our fellow citizens and it must be given high priority.

Mrs. Bottomley

My hon. Friend, as in all subjects that he captures, is a vigorous and robust champion of this topic. I am pleased that the clinical standards advisory group is to undertake a study into back pain. I hope that as a result of that work and other work that is under way it will be possible to set a specific target and programme of action so that back pain is an area in which we can make progress.

That leads me to the next theme that I wish to identify, which is action within the NHS. Back pain and the way in which it affects nurses are matters with which we are all familiar. The NHS must lead by example. As an organisation of 1 million people, it needs to be a model employer in being a health employer. Recently we launched a health at work in the NHS initiative to ensure that sensible drinking, healthy eating and smoke-free policies are carried forward within the organisation. We hope that that will be an example to other employers and that they will take sensible and responsible steps to encourage well-being within the work force.

Dr. Tony Wright (Cannock and Burntwood)

In this context it is interesting to look round the Palace of Westminster to see what this particular employer is doing. Anyone who visits the eating places, meeting places and bars will find that there is no effective non-smoking policy. I know that we are supposed to favour the politics of smoke-filled rooms, but it seems that the Mother of Parliaments has become the ashtray of the nation. Would the right hon. Lady like to comment on that?

Mrs. Bottomley

I think that the hon. Gentleman has made an excellent point. I suggest that he develops an alliance with my hon. Friend the Member for Derbyshire, South (Mrs. Currie). Of all those who have been Ministers in the Department in which I work, I think that my hon. Friend did the most to ensure that all reasonable steps were taken by managements to become "healthy" employers. I look forward to hearing from the hon. Gentleman, together with my hon. Friend, about the progress that they have been able to make in this area.

Dr. Wright

rose——

Mrs. Bottomley

Much as I enjoy interventions from Opposition Members, I do not think that I should take a second intervention from individual Members. If the Opposition initiate a debate on health in their own name, it may be possible to take further some of these issues.

We have a responsibility to thank those who work in the NHS to provide a healthy workplace, but more important is the health care that the NHS gives and the priority that it places on prevention. That is what will make the strategy work. It is our goal to provide the highest-quality health services, and it is an issue which we have taken forward in the patients charter. The Government's health strategy is more than the words of the White Paper. It is alive and is happening now because of the work of family doctors and nurses and all who work with and for the health service.

This has been described as the most significant development in public health since the founding of the NHS. The targets that we have set are challenging, but they are realistic and can be reached. Prevention saves lives and money and it can never start at too early an age. Good progress has already been made since the White Paper was published. The House may wish to know that I have today placed in the Vote Office copies of a summary of the progress to date. We are already achieving action, for two reasons: first, because of the commitment of the health service, its staff and many others working in the health field, as it were, beyond the NHS to make the strategy work. Secondly, it springs from the Government's determination to make it work and the clear lead that has been shown.

No Government in our history have been so determined to improve the health of the nation. The health of the nation has captured the high ground of health. The Labour party wanted to turn the clock back, but we have turned it forward. The health strategy is truly a great leap ahead. In 1948, better health was the good and honest intention. In 1992, we are at last turning that intention into action. The health of the nation strategy has made a vital contribution to that transformation and it deserves the warmest support of the House.

5.48 pm

Mr. David Blunkett (Sheffield, Brightside)

First, I pay tribute to all those who have argued for and contributed to "The Health of the Nation". I believe that over the years people throughout the country from health authorities, family health service authorities, the academic world and elsewhere have persuaded and cajoled the Government to take action. Today we have a golden opportunity to remove the smokescreen of benign and cherub-like innocence from the Secretary of State and to test the philosophies and values of the two main political parties.

On what does the Secretary of State insist? The answer is a debate without a Division. That is the new commitment and the new health service. That is the vigour and enthusiasm that we shall get from the right hon. Lady. We have a debate on a motion for the Adjournment of the House, a motion which cannot be amended or voted upon—what a staggering indication of the right hon. Lady's new commitment and of her confidence in her policies.

The health of the nation is not safe in Tory hands, and nor is much else. The health of our industry and our economy is not safe in their hands. Yet the health of our people and the health of our economy are intrinsically linked. The greater the fairness and equity in the distribution of wealth and the provision of public services, the greater the equality in health and, interestingly, the greater becomes the health of the economy as well.

Japan is an example of that, as was Britain during the war. In 1970 the Japanese had a distribution of wealth much the same as we have today. They have improved dramatically on the gap between the rich and the poor, and the health of their nation has improved in sequence with that.

The work of academics such as Alesina and Rodrik—they are professors in Washington, not ex-commissars from eastern Europe—shows that greater equality of income brings not only improved national health but also improved economic growth. In 24 democracies that they studied, they found that a 0.3 per cent. growth rate increase was achieved when a 10 per cent. reduction was obtained in the income of the top 20 per cent. of earners and distributed to the rest of the population.

Yet in Britain such discussions have been suppressed. The first Black report in the early 1980s had to be photocopied because the Government would not publish it. The latest edition published by Penguin provides plenty of ammunition to show why the Government have always shied away from a full debate on the original findings of scandalous decline and deterioration—which have worsened, not improved, in recent years.

Dr. Liam Fox (Woodspring)

As the hon. Gentleman has pointed out that this is a debate without a vote, will he comment on the fact that during the entire Queen's Speech at the beginning of this Session of Parliament, an agenda chosen by the Opposition, he did not choose to debate health at all? Perhaps that is an indication of the Opposition's priorities.

Mr. Blunkett

I shall certainly take responsibility from here on in about when we press for debates on health and for ensuring that we vote on motions on health at every opportunity, but the hon. Gentleman cannot divert me so easily from the substance of what is, after all, the health of the nation: equality and provision, the way we distribute our resources, and the prevention of ill health.

The Secretary of State talked about improvements in infant mortality. In five regions of Britain, infant mortality worsened last year. That is a fact. The truth of the matter is that while in the nation as a whole some people have done a great deal better, and have done better out of health promotion clinics, many others have done worse. The health divide has worsened in the thirteen and a half years of Conservative government, and it is still worsening.

There is no strategy for the health of the nation. The word strategy is mentioned on the cover of the White Paper, but there is no co-ordinated approach to the needs of the British people. Here we have a White Paper which purports to deal with the nation's ills but does not mention poverty once; nor does it mention inequality, and nor did the Secretary of State.

The Secretary of State waffled on about trusts and GP fund holding, about how wonderful the new NHS was and how tremendously it has improved. My hon. Friend the Member for Hackney, South and Shoreditch (Mr. Sedgemore) rightly asked the Secretary of State why, in that case, we are to receive a statement tomorrow about how badly the health service in London is run and what she intends to do about it.

The White Paper mentions unemployment-but only once, in the section entitled "Healthy homes", which says: Good housing is important to good health, although the interdependence between factors such as occupational class, income, unemployment, housing and lifestyle makes it difficult to assess why health effects are specifically attributable to it. Then—this would be funny if it was not so serious—the White Paper says: The Government's objective is to ensure that decent housing is within the reach of all families. Perhaps someone should tell that to the Secretary of State's husband, the hon. Member for Eltham (Mr. Bottomley), who slept on the steps of Greenwich town hall earlier this week to draw attention to homelessness. Perhaps he should have a word with a Cabinet Minister. Perhaps the new approach could be explained to him. Perhaps he could be told that the Government really do have an intention on this, even though they believe that it is muddled up with other inconveniences such as social class, unemployment and inequality.

The existence of the White Paper should be applauded. It has taken long enough to arrive, and it is at least some recognition that, even if the Secretary of State did not spend all that much time on it, the British people are willing to debate the real health causes and ill health causes in Britain—the integration of economic and social action which she did not mention. There is no real understanding of the targets of the World Health Organisation set out in 1978. In fact, the Secretary of State did not refer to them—equality between nations, regions and socio-economic groups.

The Secretary of State mentioned that there was a Cabinet Committee, where I understand that she has a little local difficulty with one of her predecessors who had a finger in everything and a voice on the radio about everyone else's Department except his own. Whenever she tries to move a policy on, apparently he blocks it. What does that Cabinet Committee do? Did it consider the pit closures? Did it meet to consider the impact of unemployment? What did the Secretary of State have to say at the Cabinet meeting? Perhaps she will tell us whether it met to consider the redundancies at the pits and in the rest of Britain. I will give way to her so that she can tell the House what it had to say. If the Secretary of State is not willing to get up and tell us, perhaps she would just nod if the Cabinet Committee did consider the pit closures. No, she is not nodding—the Secretary of State is comatose. Is there a doctor in the House?

Mr. Michael Trend (Windsor and Maidenhead)

Will the hon. Gentleman give way?

Mr. Blunkett

I do not know whether the hon. Gentleman has any medical expertise, but I am happy to give way to him.

Mr. Trend

Is the hon. Gentleman suggesting that working down mines is good for one's health?

Mr. Blunkett

What I am saying is that losing one's job certainly is not.

The Secretary of State may care to comment on the following: There are well documented effects of unemployment and poverty on health. These effects are particularly clear in the areas of psychological and mental health but there are also less clearly researched links with increased mortality and morbidity from physical illness. The large-scale loss of jobs in Rotherham (2,000 directly involved in the pits which are closing and many more in associated businesses) will affect the incidence of mental health with higher rates of depression, anxiety and, probably, suicides. It goes on to say: It is particularly inappropriate that all this will happen at a time when we are attempting to implement the Government's 'Health of the Nation' report". That was not a comment from a Labour supporter, a miner's wife or a Labour Member of Parliament. It was Anthony Baker, the Conservative-appointed chairman of Rotherham district health authority writing to his local Members of Parliament, the man who replaced the previous Labour chairman, Vernon Thorns, in the wide sweep of Government hegemony in appointments throughout the health service—jobs for the girls and the boys.

The Government have no understanding of the link between the responsibility of the individual, which we accept, and that of the wider community and nation. There is no acknowledgement of it by the Chancellor, the Secretary of State for the Environment, or the Secretary of State for Employment, who have as big a part to play in the nation's good health as the Secretary of State for Health has. The Government's attempt to take the politics out of health has failed, despite the efforts of the Secretary of State's friends in the media. The health service is one of the most highly political elements in our democracy, and the inter-relationship between one Department and another and one decision and another becomes daily more apparent.

Mrs. Dunwoody

Does my hon. Friend agree that the Government's hypocrisy goes even further? The Secretary of State talks about the need to minimise low back pain among nurses but fails to mention the Government's lack of provision of the right equipment, which would overcome that problem far quicker than any leaflet or lecture.

Mr. Blunkett

I could not agree more.

What is to happen in the autumn statement on 12 November? Will the Cabinet Committee or the Cabinet itself acknowledge that the nation's health will depend on the resources allocated to—or rather, cut from—housing, transport, local government, and education? What will the Secretary of State, a former worker for the Child Poverty Action Group, say about income support and family credit to the Secretary of State for Social Security, who not only has the job of cutting and cutting again the benefits paid to those who can least afford to lose them but has moved away from the policy of ensuring that people are supported and helped to fend for themselves, to which the Secretary of State referred in answer to my hon. Friend the Member for Birkenhead (Mr. Field) when the White Paper was first introduced to the House?

Mr. Nigel Evans (Ribble Valley)

Will my hon. Friend take this opportunity to tell the House that record sums of money are now being spent on the national health service?

Mr. Blunkett

I am certainly not the hon. Gentleman's "hon. Friend" and I will not give way on any such statistic. I am clear that the opposite is true in respect of the income of the poor. The number living on less than half national average earnings doubled in the 1980s.

Mr. Evans

What about the national health service?

Mr. Blunkett

People survive on the national health service. It is all about good health, affording a decent diet, heating homes, and otherwise living decently. It is about the environment, being able to afford to use transport, and enjoying a decent education. One in five of our children live in poverty—twice as many as in 1978. The Secretary of State smiles beguilingly, revealing a sparkling set of white teeth untouched by the accelerating collapse of NHS dental practice.

Mrs. Virginia Bottomley

I have remained unprovoked until now, but if the hon. Gentleman would like to visit my NHS dentist, I shall be glad to take him. [HON. MEMBERS: "Apologise."]

Mr. Blunkett

I should be delighted to accompany the Secretary of State anywhere—to her dentist or not. However, I never said that she had withdrawn from using an NHS dental practice. If the right hon. Lady will read Hansard, she will find that I suggested only that NHS dental practice is collapsing. The consequential threat to preventive health is something of which we are all aware, and we receive letters on that topic day in and day out.

The Secretary of State's predecessor, the right hon. and learned Member for Rushcliffe (Mr. Clarke), in a press release dated 9 October 1990, gave a clear indication that the report was to be about NHS changes. It is strange that the right hon. Lady indicated at the beginning of her speech that it is NHS changes that matter, not the nation's health.

It is 50 years since the Beveridge report was published. The key principles on which the health of the nation should be judged that that report set out included the elimination of want and idleness. That was seen as a prerequisite in creating the kind of society that post-war Britain came to take for granted. Unfortunately, that sensible and civilised society has started to disintegrate under us, as it did in the pre-war years.

At least the Green Paper recorded the target of a 25 per cent. reduction in inequalities before the year 2000, but the White Paper does not. Unlike Australia's integrated and comprehensive approach to health, Britain is making a belated stab at achieving targets—14 years after the World Health Organisation's declaration, 12 years after the United States introduced targets, and seven years after the European regional initiative.

In a statement on 8 July, the Secretary of State said: To be respected, however, targets have to be tough. To be credible, they have to be realistic. It would be folly to set a target so out of reach that we would never get there, or one which is simply an extrapolation of existing trends."—[Official Report, 8 July 1992; Vol. 211, c. 336.] In truth, the bulk of the White Paper's targets are little more than figures suggested by existing trends. Where they are not, they will be unattainable because of Government policies. Government action will make the tough targets unachievable—and where the targets are easy, the Government will have to do nothing to achieve them.

The target of a 15 per cent. reduction in breast cancer deaths by the year 2000 is welcome, but it applies only to a target group of 50 to 64-year-olds, who are subject to screening. Women below 50, who account for 20 per cent. of the incidence of breast cancer, are also crucial in treating a preventable death-inducing illness.

The Government's targets and the analysis of Government statements by the Comptroller and Auditor General in his report last year are contradictory. He stated: The Department of Health do not expect significant changes in the death rates until around the year 2000, because of the time it takes for these cancers to develop. I was unaware of that, and I will be grateful if the Secretary of State or the Minister who winds up will explain why the advice given to the Comptroller and Auditor General was different.

This country's record of treating breast cancer is so poor that immediate action is vital. Ours is the worst death rate, as a proportion of the population, in the world. Comparative figures for survival in the five-year period following diagnosis show it to be staggeringly bad. In the United Kingdom, only 58 per cent. survive, but the figure is 68 per cent. in Norway, 72 per cent. in the United States, and 73 per cent. in France. In the case of prostate cancer, the United Kingdom survival rate is only 36 per cent., compared with 52 per cent. in Norway and 65 per cent. in the United States. I do not apologise for giving those figures because it is crucial to identify not only targets but causes. What will be done about that state of affairs?

In the case of heart disease, we know that smoking is a critical factor. It is no good saying, "Ban alcohol advertising; it is just as dangerous." That showed a degree of ignorance that I found appalling. The Secretary of State confirmed that she would publish the Smee report next Thursday. Can she, or her Minister of State, also confirm that—rather than being speeded up—the report was sent back for rewriting so that it would contain a lower, more acceptable figure than the 8 per cent. drop in smoking that, according to the original report, would be achieved by a tobacco advertising ban? Opposition Members want to hear no more of this nonsense about reports being "speeded up" when, in fact, they have been sent back to be rewritten. [Interruption.] The Parliamentary Under-Secretary of State for Health has just made a cheap remark about my speech being sent back for rewriting. He is welcome to examine what the Secretary of State said about the White Paper and about improving health, and what I have said: I have tried to address the issues in hand, rather than coming out with irrelevancies.

I understand that the Government are to take a more long-term look at HIV, AIDS and what is increasingly being called "sexual health", and to decide how the current position can be improved. What about ring-fencing the existing funding, which I understand is to be reintegrated into the general health service budget? What about the special grants to provide advisory teachers, which are being cut and, in some cases, removed altogether? What use are targets relating to teenage pregnancies if family planning is being cut and teaching in schools jeopardised? What part has the national curriculum to play? Why are the Government concentrating on science rather than humanities? What action is being taken to prevent the rundown of schools provision through the local management of schools initiative, and the appointment of governing bodies which do not give a high priority to such provision?

What about health education, and teaching about love and relationships? Why is the school nursing service being cut, and why is pregnancy advice being reduced? The abortion statistics relating to under-16s are appalling. The statistics for Britain in general are appalling. In Camberwell district, 38 per cent. of all known conceptions are aborted, while in Britain as a whole the proportion is one in five. That scandal would be avoidable if we were willing to invest in proper education and advice. What is needed is a combination of the individual responsibility to which the Secretary of State rightly referred with our responsibility as a nation to invest to ensure that change takes place.

The same is true of accident prevention. The targets are a long way short of the current rate at which the number of accidents is falling. If the Secretary of State set tough targets, she would have to acknowledge the relationship between socio-economic factors and the incidence of accidents. Children in social class 5 are six times as likely to be burned or knocked down as those in social class 1. The reason is self-evident: those who live in overcrowded conditions in slums or high-rise flats, or are forced to suffer the congestion and fumes of the inner city, are clearly in a less advantageous position than those in social class 1. The study of the civil service that is currently being undertaken did not need a great deal of money to prove that the health of clerks is worse than that of people at and above under-secretary level. No one needs to be a genius to know that living in squalid conditions worsens health.

Mrs. Bottomley

I have degrees from Essex university and the London School of Economics, I have worked for the Child Poverty Action Group, and I have lived with the defeatist talk that we are hearing from the hon. Gentleman. Of course he is right to say that there is an association between health and all the factors that he has mentioned. That is why such health variations are part and parcel of the health of the nation strategy, and that is why the Cabinet Committee is so important, involving Ministers from the various Departments.

What the hon. Gentleman has failed to identify is how, in the context of many adverse social, economic and employment factors, we can reach out and provide a decent health service. That is what the GP contract did, what the immunisation targets have done, what the cervical cancer screening services have done and what the deprivation payments have done. That is what we seek to do, rather than adopting a defeatist attitude to the delivery of health care. We must ask how we can ensure that the health service reaches ever higher targets in areas of great social difficulty.

Madam Deputy Speaker

Order. I remind the House—and that includes the Secretary of State—that interventions, by their nature, should be short.

Mr. Blunkett

I am delighted to find that the Secretary of State is, after all, traumatised rather than comatose.

The truth is that a Secretary of State whose White Paper does not once mention poverty or inequality, and mentions unemployment only in passing—dismissing it as part of the section dealing with housing—cannot give Opposition Members any lectures about the university that she attended or the studies that she undertook. Deprivation and inequality in incomes are worsening the ill health of those at the bottom of the pile.

Let me take on the Secretary of State in regard to the subject of mental health, on which she has a well-deserved reputation. The section on mental health in the White Paper mentions suicide. The incidence of suicide is twice as high among unemployed men as it is among those in work, and premature deaths are one third higher. The Secretary of State can give me no lectures about her belief in equality or fairness.

What, then, would Labour do? Economic action is vital. We need greater equality, full employment and a new commitment to decent housing, adequate public transport and good education. Unlike the Conservative party, we are committed to health promotion and to primary health care in its widest sense. We are committed to investing in community care, so that we can support people at home rather than in private residential institutions.

We are committed to investing in our communities—investing in integrated community and hospital services, and in the reintegration of purchasing to ensure that coherent priorities are met. We are committed to unified district health authorities and family health service authorities; to abolishing GP fund holding, which has distorted purchasing priorities; to supporting and expanding the healthy cities initiative, which the Secretary of State did not mention; and to linking economic and social policies for the real health of the nation. We are committed to the development of GP contracts which actually deal with ill health where it matters most—rather than health promotion clinics to make more middle-class people even healthier in south-west Surrey—and to directing resources towards improving the mortality rate.

In the past year, 42,000 people would not have died if social class 5 had been able to enjoy the income, conditions and well being enjoyed by social class 1. It is not just a matter of politics; it is a matter of life and death for 42,000 people a year, 3,000 of them children.

We need a strategy for health, with a clear inter-departmental approach to the health of the nation. We need policies which are in the interest of the people, not in the interest of those who pay the Tory party. I refer. of course, to the state of Virginia, and what a state it is: the state from which the most predominantly used tobacco in Britain is obtained. A well-known brand is called Golden Virginia. We would ban tobacco advertising and introduce clear warnings. We would protect people from passive smoking and act against those subsidised European tobacco growers to whom the Secretary of State referred. Tobacco is the biggest killer in this country apart from poverty. That is why we would act against it. That is why 800 doctors put their money into and their names to the advertisement in The Independent today. That is why the Secretary of State should not have pre-empted the publication and recommendations of the Since report by dismissing them before they even appeared.

We shall put the health of the nation first. We shall put people before party. We shall be willing to put our policies to the vote.

6.20 pm

Mrs. Marion Roe (Broxbourne)

I am grateful for this opportunity to speak in the first health debate of this parliamentary Session—the first since I became Chairman of the Select Committee on Health. I am very proud and privileged to serve on such an important Committee. It has awesome responsibilities, as all who are involved in health care know so well. We shall certainly look forward to welcoming next week my right hon. Friend the Secretary of State to give evidence to our inquiry into tobacco advertising.

I pay tribute to my predecessor and to former members of the Committee who steered it so ably for 15 months. I am particularly grateful to the last Chairman. As part of his legacy, he has left me an excellent and acclaimed report on maternity services, about which I shall say more later.

Unlike the hon. Member for Sheffield, Brightside (Mr. Blunkett), I pay tribute to the Secretary of State for bringing forward publication of the White Paper "The Health of the Nation". There can be little controversy about the essence of the policy: to make people more aware of the need to be healthy.

When the hon. Member for Brightside complains about the Government's policies concerning poor housing and homelessness and their effect on health, I remind him, first, of the enormous sums of money that are being poured into the estate action programmes to revitalise derelict housing estates and, secondly, of the fact that the Labour party bitterly opposed housing action trusts, the purpose of which was to bring back into use thousands of empty homes, owned by Labour-controlled councils, that are in disrepair through neglect and bad management. So much for the Labour party's concern over homelessness.

The Select Committee on Health will shortly start an inquiry into NHS dental services, an inquiry which I hope the hon. Member for Brightside welcomes.

It is entirely sensible that the Government should concern themselves not just with being able to cope with ill health, and all that that brings with it, but with doing all that they can to prevent the onset of illness. Ill health is a tragedy, in terms not just of the waste of a country's resources but of the human cost—a matter of much greater concern to us all. It leads to the loss of the breadwinner, the awfulness of seeing a child suffer and the strain of long-term nursing or of coping with a relative who is severely disabled. All these things can bring with them untold human misery.

It is good to see the Government taking the initiative and, once again, being proactive rather than reactive. The health service reforms, for which successive Conservative Governments are responsible, are shaping a health service that is better able to meet the huge demands upon it. That is a subject for the nation's gratitude and pride. Millions more patients are receiving the treatment they require, and millions more are being treated for ailments that even 10 years ago could not be treated. Let us, however, be in no doubt that demand and public expectation will continue to put heavy pressure on our health services. That is why I welcome this initiative.

It is important that those of us who can do something to protect ourselves against ill health should do so, in order that the people who need treatment can receive it as quickly as possible. As a Conservative, I put great store by the responsibility of individuals to look after their own health, but that responsibility must be grounded in informed choice and a sharing of common objectives. We cannot legislate to stop people drinking, smoking, or even having sex, but we can and should inform them of the consequences of their actions.

Moreover, I believe that greater understanding of what is good and bad for us will lead to greater willingness of people to work together. For example, it is a pity that, when a family adopts a healthy diet at home, there is little encouragement, in schools or the staff canteen, for people to eat sensibly. Therefore, I am pleased that the White Paper places emphasis on health alliances between different agencies, groups and organisations. I hope that the Government will ensure that they all work together to produce common and easily understandable messages.

I congratulate the Government also on moving the health debate forward. As we have heard, much has been achieved already. Anybody who has seen a child with whooping cough or struck down with measles knows how sensible it is for children to be immunised. Similarly, any woman who has been saved from the horrors of cancer by timely screening is aware of the value of preventive medicine.

It is right that the goalposts should be widened, new targets set and our sights raised higher. While I applaud the Government on publishing the White Paper, I am concerned that the impetus that led to its publication should not be lost. When I read the White Paper, I was struck by the myriad good intentions. It speaks of targets to be attained, by means of strategies and schemes to be developed, of reports to be made and of action groups to be set up.

A great deal of activity is promised. Although a Cabinet Committee will oversee the implementation of the overall strategy—which I welcome as a positive sign of the Government's commitment, as well as their promise of periodic reports—would the Secretary of State contemplate issuing an annual report so that achievements could be recognised and unsatisfactory trends acted upon quickly? Such a report could be on the same lines as the chief medical officer's annual report on the state of public health. This one, however, should concentrate on the specific key areas and targets mentioned in the White Paper.

The White Paper contains many matters of enormous interest. My Committee will look at them, in particular at those which relate to pregnancy and childbirth. The Select Committee on Health has done an exceptional amount of hard work on the maternity services and has produced a report that has been well received by the Government and professionals alike. The importance of good maternity services for the welfare of the mother and the well being of the child cannot be emphasised enough. That is at the centre of the Committee's report. It places emphasis on the provision of continuity of care for the mother throughout pregnancy and childbirth.

There are many other recommendations, most of which are designed to promote the health care of both mother and baby so as to avoid complications or unnecessary illness—aims that are entirely compatible with those in the White Paper. Some of the recommendations, especially those at local level, are being acted on and others are being studied. At the last count, three committees were considering the different points that the Select Committee had raised. Midwives and I hope that the committees will report as soon as possible so that the Select Committee's recommendations can be acted on quickly.

I should like to take the debate on maternity services and the welfare of the mother one step further. Few people are aware that as many as 10 per cent. of all recently delivered women develop post-natal depression. In some cases, depression may be so severe that women need out-patient psychiatric help, and many need drug therapy. In view of its common occurrence, it is surprising that so little attention is given to it. Many books on pregnancy and childbirth hardly mention it, if at all, and it is not usually discussed in ante-natal classes.

Many mothers who are at risk could be picked up. Mothers who are most at risk are those who have had a history of mental illness or a tendency to it within the family, those who have experienced fertility problems and who experienced a difficult birth with their child—who may have experienced a lot of intervention—or those who experienced the trauma of a child being taken into special care.

My right hon. Friend the Secretary of State rightly pinpointed tackling mental illness as one of her key tasks. Mental illness is a double curse, because it is so destructive of a person's confidence and of his or her ability to help themselves. In that context, post-natal depression is doubly vindictive, because a mother becomes frightened for herself and particularly frightened about her ability to look after her baby. More could be done to recognise the dangers of this affliction. I urge my right hon. Friend to consider this matter as appropriate for inclusion in the overall objective of reducing the incidence of ill health caused by mental illness.

6.32 pm

Mrs. Alice Mahon (Halifax)

I congratulate my hon. Friends the Members for Sheffield, Brightside (Mr. Blunkett) and for Bristol, South (Ms. Primarolo) on their elevation to the Front Bench. We have a new team, who I think will do a first-class job for the party. I was impressed by the opening remarks of my hon. Friend the Member for Brightside.

I should declare my education. I did a degree at Bradford university and spent 11 years working in the national health service, which may explain the different approach of myself and the Secretary of State. The White Paper is an attractive publication, and if I were giving the Government marks out of 10 on how it looks they would be reasonably high. If I were giving marks for its content, they would be fairly low, because it is fairly lightweight and skirts around many of the issues that we believe to be important.

What is not included in the document is vital to the health of the nation. My hon. Friend the Member for Brightside mentioned Beveridge. Fifty years ago, in 1942, when Beveridge drew up the famous plan that gave birth to the national health service, he outlined what he saw as the five giant evils of the day—want, disease, ignorance, squalor and idleness. The NHS was to be part of the attack on those evils, particularly on disease. However, he made it clear in his report that they were all linked. He knew that one could not attack disease without attacking how people spent their lives, what they ate, how they were educated and how they fed, housed and clothed themselves.

On publication day in 1942, a mile-long queue formed outside the Government bookshop in central London and around 70,000 copies were sold within hours. Three weeks after publication, a Gallup poll found that 19 out of 20 adults had heard of the Beveridge report and that most approved of its recommendations. It touched the heart of the nation, which awoke to the content of the report like a slumbering giant. People stirred and voted for a Labour Government, who introduced the national health service, and we should never forget that.

We are witnessing a similar phenomenon today with the Government's callous and inhumane treatment of the miners. Yesterday, we saw the Government's hatred of anything collectivist or anything to do with communities. The Government should be fearful of the mood that is abroad, which we witnessed yesterday. Since they announced the pit closures, we have seen what I, as an old trade unionist, would call a massive failure to agree between the people of this country and the Government. The British people will put the national interest first, whereas the Government will put first their idol—the market.

The report is a wasted opportunity. How can any document on the health of the nation fail to address such issues as poverty, low income, bad housing, homelessness and unemployment? Page 26 of the document mentions healthy cities, healthy schools, healthy hospitals, healthy workplaces and healthy homes", but fails to offer any solution to the housing crisis, so it is worth nothing. It does not acknowledge that the housing crisis is the worst since after the war. Halifax is not the poorest town in the country by any means, but almost 7,000 people are waiting to be housed by the council. An average of 100 families are made homeless every week, and young people sleep rough or on somebody's settee.

The White Paper could have begun research into homelessness to find out exactly how many people are suffering from it, but it chose not to do so. It could have considered the inner cities and how many unemployed people experience had health because of the stress of unemployment. It could have undertaken research into the inadequacy of the benefit system.

Mr. Nigel Evans

Does the hon. Member agree that the greatest number of empty council houses are under the control of Labour authorities as opposed to Conservative authorities?

Mrs. Mahon

I absolutely disagree with that. The statistics support my argument, but I do not want to go into them.

Page 28 of the White Paper says that the Government will continue to pursue its policy to promote choice and quality in housing, having regard to health and other benefits. Those are empty words; the White Paper offers absolutely no help. If the Government want to help, the Minister and her colleagues could contact their friends in the Department of the Environment and ask why they will not allow councils to spend their capital receipts on building affordable housing to enable people to move out of squalor and into decent homes. Why did not health Ministers object to the enactment of the Housing Act 1988, the new rules of which made tenants so insecure and caused much more stress? Why do they not do something about what is happening to housing associations, which were to plan for special-needs categories such as elderly people? Housing associations now have to find the money to repair and maintain their properties, whereas previously they received grants. That repair and maintenance bill is being met by tenants and pensioners, who can ill afford it.

Report after report has highlighted the state of our crumbling schools. The White Paper talks about our schools being healthy places. Health Ministers should get in touch with the Department for Education and also ask the Prime Minister what he will do to tackle the backlog of maintenance in some of our schools.

The Government poll-tax cap the poorest councils in the country, so they can do nothing about housing.

What upsets me most about the document is the way in which it refers to nutrition and to advising people to make healthy alliances between different agencies, without ever mentioning schools meals, which have played an important role in the nutrition of children, especially children from poor families in this country for nearly 100 years.

In 1906 an Act of Parliament enabled councils to raise money on the rates to provide school meals, and the Education Act 1944 made it compulsory for every local authority to provide a school meal for any child whose parents so wished. Children's health is clearly related to the food that they eat, yet the schools meals service has been under constant attack from the Government since 1979.

The Black report, to which my hon. Friend the Member for Brightside has already referred, valued schools meals so highly that it recommended that they be provided free, yet in the same year the former Prime Minister, now Lady Thatcher, abolished local authorities' obligation to provide meals, except for children entitled to free school meals—yet she was the one who talked about letting children grow tall. Unfortunately, she meant only those children whose parents had healthy bank balances. Since the Education Act 1980, school dinners are no longer required to meet nutritional standards. The Secretary of State should at least have included that fact in her document.

In 1988, 400,000 children lost their entitlement to free school meals following changes to the Social Security Act, and compulsory competitive tendering threatens the very existence of that valuable, indeed vital, service.

As a member of the Select Committee on Health, I tried to get the Committee to recommend that school meals should be provided for all children at an affordable price or free for people on very low incomes, and that national nutritional guidelines should be restored. That was when we drew up the report on pre-conceptual care, which preceded the maternity services report. The first of those reports emphasised the need for a healthy diet, so that healthy parents would produce healthy children. That seemed like common sense; it did not seem revolutionary, but something which we should all encourage. Alas, another golden opportunity was missed, because Conservative Members have voting habits which in our opinion harm the health of the nation time and again.

Another key area identified in the report is that of HIV infection, sexual health and drug abuse, especially involving young children. The report's treatment of that area is light weight. Why are the Government not funding the health education co-ordinators' post from March 1993? Health education co-ordinators have been praised by everyone including Her Majesty's inspectorate from the Department for Education. They do a valuable job to combat a scourge which we all deplore—young people getting involved with drugs. Yet the Government will not fund them. Clearly councils cannot afford to do so. If the Secretary of State really believes that she can attain her targets and reduce such abuse she must rethink the approach to that problem.

The White Paper identifies mental illness as a problem. In an earlier intervention, I tried to question the Secretary of State about prescriptions and health benefits. If people with a mental illness live in the community and are hard up they still have to pay for their prescriptions—many people in benefits have to do so. Often those prescriptions are not renewed, the person regresses and ends up back in hospital. It is a false economy not to ensure that such people get their medication.

The Secretary of State should be able to answer a question from a Back Bencher about whether the review on health benefits is anywhere near complete.

I am conscious of the time, so I shall make only a couple more points. The Select Committee's report on maternity services expressed horror that the DSS could not comment with authority on the adequacy of income support rates for providing a balanced diet for pregnant women because the research was not available—some members of the Committee had already known that, but some had not. Any document that does not deal with that problem has singularly failed in its duty to pregnant women. The omission is disgraceful.

We concluded, too, that there should be no discrimination in benefits for pregnant women. Why should women under 25 get less in benefits than older women? There is nothing in the document to support the recommendation in the Select Committee's excellent report.

I understand that today the Government launched their Winter Warmth telephone line, which is intended to do something about elderly people and fuel poverty. Any elderly or sick person who believes that he or she will receive help with fuel bills or insulation costs will be bitterly disappointed. The scheme, like the document before us, is a candy-floss scheme, pretty on the outside, but with little substance inside. I should like the Secretary of State to go back to the drawing board and bring back to the House a report that really attempts to slay the five giant evils identified by Beveridge. Goodness knows, there have been enough victims of Conservative health policies over the past 13 years to make that a priority.

6.45 pm

Mr. Sebastian Coe (Falmouth and Camborne)

I am grateful to have the opportunity to address the House this evening. Hon. Members may recall that the last time I was due to deliver my maiden speech an altogether different delivery overtook me—the birth of my daughter, a week before the House rose for the summer recess. I link that comment with my great thanks to Epsom general hospital for what they did not only that evening, but throughout the week that my wife spent there.

First, I must pay tribute to my predecessor for his deep commitment and personal involvement with the Falmouth and Camborne constituency, with whose stewardship I am both privileged and proud to have been entrusted for the foreseeable future. I pay tribute to his predecessors, too—from both sides of the House—who ably served my constituents during the long and proud history of the Falmouth and Camborne division. I also thank the people of my constituency for giving me the opportunity to serve their interests in this place.

The Falmouth and Camborne constituency is unique and vibrant and so are its people. They come from a breed that has long learnt to eke out a difficult living against hostile elements—at sea, on land, or under the ground. It was in view of the rich and strong tradition of tin mining, and because of the generations of miners who sought their livelihood in that industry, that my decision on the vote last night was so marginal. I greatly welcome the review of the mining industry announced by the Government.

Since the loss of the tin mining industry, my constituency has never fully recovered either as a community or as an economic area. That may change now, and we have to encourage a level of industry and other economic activity which I hope will continue. Certainly this constituency's current Member of Parliament will press at every available opportunity the needs, desires and hopes of his constituents.

As an apprentice and a newcomer to the team, I thank many hon. Members for the support and guidance that I have received in the past few months—and, of course, I offer my thanks for the invaluable advice that is always available from the Whips Office.

In my previous life, I had advice, and guidance usually given after the event, from coaches, from team managers and from trainers. Sport has never been noted for its 20/20 foresight.

There is a far more important and serious issue that I wish to address today. The nation's health and fitness is an issue in which effective advice and guidance can literally be a life saver. The single most important factor in the future success of the United Kingdom, either as an economic or as a cultural force, is the health and well-being of its citizens. The provision of an effective and efficient national health service, free to all, is fundamental to the future prosperity of this country. No hon. Members here today would dissent from that view.

What we can argue about is the way in which the service is delivered and resourced, and what its priorities should be. The Government have unequivocally pledged the continuation and development of a national health service free at the point of delivery. That overriding principle must for ever be upheld and constantly repeated. It is the one non-negotiable, fundamental principle in my book.

The aim must be to continue to improve a free national health service, but a free national health service does not preclude the demolition of a number of apparently sacred cows, nor does it preclude the re-ordering of priorities within the system, provided of course that that re-ordering is based on solid reasoning, produces tangible benefits for patients and other users, and is fully explained to national health service employees and users alike.

Those who believe that the structure and organisation of the national health service should remain inviolate in the face of medical advances and demographic changes, the sole requirement being simply more funding, do not reside in the real world, nor do they have any genuine regard for the effective use of public finance or resources.

The national health service is Europe's single largest employer, with more than 1 million people and a budget of more than £36 billion, in itself an increase in real terms of 48 per cent. since 1978–79. Those figures are impressive, but as politicians we must recognise that they are Monopoly figures, literally too large for many people to grasp.

In truth, we must also realise that £36 billion matters not a jot when a person's sole concern is whether there is an ambulance, a doctor, a waiting room, a surgery, a hospital bed or a nurse immediately available when needed. As over the years the national health service has come to be perceived as available on demand, such concern is understandable.

Of course the reforms were overdue and hugely welcome, but within them there are still a few issues which need teasing out. One crucial issue, which I believe receives far too little attention and resourcing, is health promotion and education. The best way to help the national health service is to ensure that people do not become ill in the first place. While we go about our duties in the House next week, 455 people will die from coronary heart disease. As we go about our duties in this place next year, 40 million days will be lost through that disease. When we link that to the simple statistic that £2 billion-worth of production will also be lost, we know that those statistics should lie heavily on every Government departmental desk.

The deaths and losses will not be spread evenly throughout the country. The poorest sections of our community in the inner cities and the rural areas will shoulder more than their fair share of that burden. For towns such as Redruth and Camborne, which are an amalgam of the two, that burden will be noticeable.

The real crime of the figures is that they are preventable because the causes are preventable. We have heard about some of those causes today: being overweight, too little exercise, high blood pressure, high cholesterol levels and smoking. Yet while the national health service will spend £500 million next year on the treatment of coronary heart disease, it will spend barely one fiftieth of that on prevention of the same disease.

Tobacco, alcohol and confectionery manufacturers will spend about £700 million next year on advertising their wares—20 times the budget currently going into health education. Strikingly, the Government will also take £12 billion in excise duty and tax from alcohol and tobacco. I find those figures difficult to reconcile, just as I continue to find the sponsorship of sport by tobacco companies irreconcilable.

It is abundantly clear that there must be more resources and that a higher priority must be given to health education, properly targeted at the section of the population who are most in need. There have been a few tentative though welcome bites at that particular cherry. The White Paper "The Health of the Nation" places health promotion high on the agenda with preventive campaigns targeting particular diseases, such as breast cancer, cervical cancer and AIDS, and unhealthy practices such as drug abuse. That is welcome, as are the significant role and efforts of the voluntary sector and the whole raft of charities operating in this arena.

One issue which must be addressed is the complete separateness of health promotion, and sport and recreational departments at national and local level. There is a wide recognition in the White Paper that moderate and careful exercise is a crucial ingredient in every individual's good health and well-being, yet the public fund two organisations—the Health Education Authority and the Sports Council—with their attendant administrations, broadly to undertake health and fitness promotion. I had the unique experience of serving on the boards of both organisations. It is clear that they will have to work far more closely together to avoid the inevitable waste of precious resources and the duplication of time, effort and funding. Their co-operation with the Department of Health in the national fitness survey is welcome, as is the Department's inclusion of the physical activity policy development group, which is a further welcome move along that road.

Part of the work of the group is to consider the feasibility of setting targets in physical activity and how they might be achieved. However, I find it a little disconcerting that in the 20 years since the inception of the Sports Council and in the 10 or so years since the inception of the Health Education Authority's predecessor, the Health Education Council, we are only now turning to physical activity targets and the prioritisation. At the end of the day we cannot force people to adopt active, healthy living patterns. What we can and should do is to ensure that as wide a range of information, advice and guidance is freely and readily available to everyone. The final choice will be for the individual, but that choice must be an informed one.

Several Hon. Members

rose—

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)

Order. No fewer than 20 hon. Members wish to catch my eye during the debate. It would appear that some of them may be unsuccessful. It would be helpful if hon. Members would bear that in mind and be as brief as possible.

6.59 pm

Ms. Liz Lynne (Rochdale)

I pay tribute to the hon. Member for Falmouth and Camborne (Mr. Coe) on his excellent maiden speech.

The White Paper states that there are significant variations in ill health in England and other countries. Why are there variations? What will the Government do to rectify them? I have concluded that the health of the nation depends on the wealth of the nation. There are areas of England which are obviously less prosperous than others. Some members of the Government at last seem to be admitting that wealth is a factor in health. We need more job opportunities and better housing. Those two factors alone have an enormous impact on health.

I am glad that the Government have at last recognised that. However, instead of simply recognising it, they should act. They should be providing more jobs, not fewer. The Government should announce today that they will allow councils to spend the money raised from selling council houses so that people can have decent, healthy homes in which to live. If one lives in rundown, damp housing, one is more likely to suffer from bronchial conditions. Everyone knows that poor income and poor health education lead to poor diet, which in turn leads to heart disease, diabetes and so on.

The Government have raised many hopes with their White Paper, in the same way that they raised many expectations when they originally announced their community care reforms. The White Paper states that it is important to maintain the quality of care and support provided for chronically sick people, elderly people, mentally ill and handicapped people. However, many people who work in community care doubt whether, come April 1993, those good sentiments will become a reality. Similarly, there are fears that all the fine words in the White Paper are just that and have no substance.

The White Paper admits that the success of the strategy will depend on the commitment and skills of the health professionals within the NHS. I hope that the Government will now value and properly reward those professionals who carry so much of the burden of introducing those reforms.

I am pleased that the Government now accept that smoking is an addiction and will encourage people to stop smoking and prevent children from starting. However, I am disappointed that no extra money has been pledged for anti-smoking campaigns. I am appalled that the Government have failed to enforce a tobacco advertising ban, when evidence from New Zealand and Norway shows how effective a ban can be, particularly with children.

As has already been said, more than 700 British scientists and clinicians have paid for an advertisement in today's Independent stating that there is now strong evidence that tobacco advertising encourages children to smoke. The Government should listen to those who know. I hope that Hanson and Rothmans, who each gave £100,000 to the Conservative party in the latest year for which figures are available, are not affecting the Government's policies.

According to a Health Education Authority report, one in five people in my constituency die every year as a result of smoking. An estimated 599 residents were admitted to an NHS hospital because they had an illness caused by smoking. Those figures come not from a tinpot organisation, but from a book published by the Health Education Authority. However, the Government have still not banned tobacco advertising. What stupidity, cynicism and short-sightedness.

The White Paper targets four types of cancer for reduction. I welcome the inclusion of breast cancer in that list, but note that the 25 per cent. reduction applies only to "those invited for screening". The Government concentrate on the 50 to 64 age group. There is no guidance for general practitioners to screen women over the age of 40 in families with a history of breast cancer.

Cancerlink is disappointed that no targets are given for treatment and support. The quality of life of cancer patients has been left out of the White Paper. The inadequacy of resources available for personal and family counselling must be tackled.

With regard to mental health, there is no mention of the fact that there may be a link between mental health, homelessness and redundancy. What sort of health problems have the Government caused the miners and their families over the past few days? The way in which the pit closures were announced was callous in the extreme.

However, more than that, as a consultant psychologist has said, the sudden shock of the announcement of such a speedy and savage cut is equivalent to a sudden bereavement, road accident or terrorist bombing. Some people may never recover from the way in which the announcement was made. However much the Government might change their mind, the immediate shock was real; the stress has been caused and the damage has been done.

The White Paper contains no specific targets for the reduction in the incidence of mental illness or for the promotion of mental health. The Alzheimer's Disease Society is especially disappointed that the Government have not set targets. There should be targets for support and accommodation for those leaving long-stay psychiatric hospitals.

The continuing squeeze on local authority budgets and reduced funding for the voluntary sector is completely ignored. Anyone who believes that that is not important should see the number of homeless people sleeping rough in London. People are also sleeping rough in Manchester and every other city in the country. A number of those people suffer from mental illness.

I welcome the fact that accidents feature in the White Paper. However, like the Royal Society for the Prevention of Accidents, I wonder why non-fatal injuries are excluded. Non-fatal injuries cost a lot more in total than fatal injuries and many injuries lead to medium and long-term disabilities.

Alcohol targets are dealt with under heart disease and accidents. That is disappointing, because alcohol is related to a wide range of medical conditions and deserves its own heading. I would also like the Government to give a commitment on complementary medicine. The full benefits of that type of health care are not yet fully understood.

All in all, I welcome certain aspects of the White Paper—at least it is better than nothing. At last we have some sort of strategy for health, but it does not go far enough. What good are those fine words if the money is not there?

I ask the Minister to make a commitment today that the health budget will not suffer when the public spending cuts are announced and to announce that there will be a real, substantial increase to meet the health needs of the people of this country. Anything less than that commitment makes a mockery of the White Paper.

7.8 pm

Dr. Charles Goodson-Wickes (Wimbledon)

It gives me great pleasure to congratulate my hon. Friend the Member for Falmouth and Camborne (Mr. Coe) on his maiden speech. He has shown his dedication, ability and achievements in other fields and I am quite confident that, whatever distance he chooses here, he will be as successful. We look forward to hearing more from him. I am aware in particular of his interest in the ghastly problem of the misuse of drugs in sport and we look forward to hearing him pursuing that line as well.

After my right hon. Friend the Secretary of State for Health made her debut in the health conference in Brighton, my wife said to me, "Doesn't she look pretty?" I countered by saying, "Didn't she make a good speech?" I should make it clear to my right hon. Friend, in her temporary absence, that those compliments are not mutually exclusive.

"The Health of the Nation" has been considered very widely in its Green and White forms over the past 16 months. I urge the House to make certain that we maintain the momentum and achieve another target—its implementation by April next year.

Never has the phrase "prevention is better than cure" been more appropriate. I talk, I believe, as the only practising physician or surgeon in the House. I have been involved in preventive medicine for 20 years, in the Army and on behalf of many companies ranging from mining and engineering to the service industries. I was also proud to serve on the medical advisory committee of the Industrial Society. My right hon. Friend the Secretary of State has more than a passing acquaintance with that society through her father's outstanding leadership of it.

However, there is still widespread ignorance of the issues addressed in the White Paper, not least because the emphasis on medicine, that unique blend of science and art, has historically and naturally concentrated on curing illness. The advent of screening medicine to detect conditions in the early stages and to be able to make a pre-symptomatic diagnosis, linked with advice on how to avoid other afflictions, is a relatively new concept. It has largely been pioneered in this country by the private sector, but the national health service has played an important part. Perhaps we are seeing an acceleration of the trend of having a health service rather than a sickness service, with the ultimate aim being the physical and mental welfare of everyone in this country.

I have often noted over the years that if one says that one is involved in occupational medicine it is a conversation stopper. That branch of medicine, catering as it does for the effects of a job on a patient's health and vice versa, might be an important aspect of the evolution of health care in this country. In France, many—perhaps most—employees are entitled not only to a preemployment medical but to a retirement medical and, often, annual medicals which might or might not be funded wholly or partly by the state. The context of a schedule for screening will obviously vary widely in depth and quality, but the legitimacy of various tests is constantly being reassessed. I agree with the hon. Member for Rochdale (Ms. Lynne) that one should re-examine the age limits for breast screening for women.

"The Health of the Nation" also addresses a rather more parochial issue—health in the workplace. We should be doing ourselves a disservice if we did not start to consider our own lifestyle in this place. In my written evidence to the Select Committee on Sittings of the House published in February, I said: As a practising physician I have to see colleagues, and in particular Ministers, being forced to live a lifestyle which is incompatible with their general well-being, and I am convinced these factors militate against their making properly considered decisions. In particular, the necessity for Ministers to come to the House at bizarre times of the night and early morning is indefensible. The Jopling Committee has also made a recommendation. It is interesting for the House to note the opinion of the 1959 Procedure Committee. I say this in the context of the numbers game that we had to play before last night's Division. The 1959 Procedure Committee stated: Members who are seriously ill should never again be required to attend to record their votes". I very much hope that Madam Speaker will soon organise the conference to address that matter.

Perhaps an agreeable spin-off from the publication tomorrow of the Tomlinson report will be consultants taking redundancy and redeploying their skills in the development of preventive and occupational medicine. Those matters cannot be wholly funded by the NHS, and ample opportunities exist for co-operation between the NHS and the private sector. Only a few weeks ago I attended the opening of a magnetic resonance imaging screening unit in the grounds of Atkinson Morley's hospital in my constituency. That hospital pioneered CAT scanning about 20 years ago. The equipment for that is extremely expensive. It is owned by a private company which has a lease on the area, and Atkinson Morley's hospital provides the patients and the medical, surgical and, most important of all, radiological back-up.

Such sophisticated equipment obviously costs a great deal of money. Of the 90 units of M RI equipment in this country, about one third are privately owned, one third are owned by charities or by charities in combination with the NHS and one third are owned by the NHS itself. It is the most startling equipment and it will have an exciting future. I recommend that all my colleagues share the fascination of being able to look directly for the first time at organs and structures of the body. It is the most extraordinary thing to come on the scene since I qualified as a doctor, which I suppose marks my age rather than anything else.

On a more basic level, how will we ensure that vital—I mean "vital" in the proper sense of that word—preventive measures are carried out by GPs? The answer clearly lies in the new contract, which was very painfully negotiated, and the advent of the increasingly popular GP fund holders. The House will remember the outcry that we had to face from doctors who, having been trained in an NHS ethos and knowing no other, were initially horrified to have to take more administrative and commercial decisions in their practices. Opposition Members, on wholly outdated ideological grounds, also whipped up discontent and, more important, alarm in the general public about fund holding and NHS trusts. That was done under the entirely false argument that the trusts were "opting out" of the NHS. Only today I visited St. Helier's national health service trust which serves much of my constituency. It is enthusiastically planning targeting for the implementation of "The Health of the Nation" in next year's budget.

I do not know whether it has sunk into Opposition Members' minds that another intellectual conversion has occurred in their party and, incidentally, within the British Medical Association, my trade union, which swayed from militancy to guarded warmness about the proposals, but which is still being mealy-mouthed about them. I wonder whether Opposition Members understand the changes that are taking place. I should not have thought so, judging by the speech of the hon. Member for Sheffield, Brightside (Mr. Blunkett). Only a month ago we read in The Times that the shadow Health Secretary, in the form of the hon. Member for Brightside, would abandon the Labour party's policy of abolishing NHS trusts and GP fund holding and drop the campaign to restore so-called underfunding in the NHS. I read the article in The Times and I heard the hon. Gentleman today. He owes it to the House to clarify his exact position and to say whether he carries the rest of his party with him. GPs running their own budgets will be able to achieve much more at the primary care level and thus take pressures off hospitals and give themselves more clinical satisfaction.

All the admirable proposals in "The Health of the Nation" can be carried out without creating a nanny state. When I have a recalcitrant patient—

Mr. Deputy Speaker

Order.

Dr. Goodson-Wickes

May I just finish my sentence?

Mr. Deputy Speaker

Order. I call Mrs. Gwyneth Dunwoody.

7.18 pm

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

Targets are all very well if they are realisable and sensible. The fairgrounds of my youth had vast numbers of machines that people were required to hit with an enormous hammer and a bullet then shot up and rang a bell. Very few people managed to do that because the machines were deliberately rigged. The similarities between the rigged bells and the targets of the White Paper seem very clear indeed.

I have strong views on the prevention of ill health. It is something for which I have pleaded for a long time. It is utter hypocrisy to suggest that we need proper health targets and then refuse to make the direct connection between the provision of funds and the provision of services that would allow us to hit those targets. That has probably been the worst con trick that the Government have tried on the British public for many years.

When talking about reducing smoking, one must understand that it is necessary to cut back advertising for smoking, particularly that aimed at young people. The length of time that people smoke is one of its most hazardous and appalling aspects. Some 1,149 people die every year in my constituency; of those, 179 are the result of smoking-related diseases—one in six of the deaths in my constituency. But there is still no clear plan from the Government about what they intend to do. They simply promote a lot of generally cheerful ideas stating that it would be nice if we were to cut down on smoking.

No matter which target in the document one examines in depth, one comes to the same conclusion: there are many pious hopes. The Government say that it would be wonderful if they could make it much easier for people to receive health education and could reduce the number of teenage pregnancies. However, there has been a consistent chopping of the provision of information to young girls on the need for proper health planning or the sort of service that they can easily receive. The results can be seen in every hon. Member's surgery when they are asked to provide houses for young people who are often homeless and pregnant. That connection is direct, not accidental.

We can take that argument further. We are told that one of the main targets is the provision of good health care for the elderly. In my constituency we are constantly told that we are lucky and that the reorganisation of trusts has improved health care—it is important to keep repeating this claim. The money keeps running out and the number of beds keeps being cut, but according to the Government my constituents should realise that they are getting a better service. As if those changes are not enough, we even have an ambulance trust created specifically as an independent unit. It has considerable problems related not only to its equipment but to the provision of its services throughout Cheshire and other parts of Merseyside.

We are moving towards what is lightly called community care. There is no better idea than community care, but it is not a cheap option. It must be provided not in the terms suggested by the present trusts—reducing the number of geriatric beds and ring fencing small sums of money that are inadequate to provide alternatives in the community. It must be provided by highly skilled nurses and support in people's homes given by health professionals. That requires a good, constant supply of money, but it is clear that such sums will not be forthcoming.

I asked my local trust what would happen when two of the geriatric hospitals were closed down. I do not pretend that they were adequate, but they provided health care and protection for many of my elderly constituents. When I asked about the closures, I was told that other wards would be made available in the district general hospital—itself a trust. But the wards to be built in Leighton hospital will not replace the beds lost by the closure of the Barony hospital. It was never intended that the money from the sale of the Barony and Arclid hospitals should be diverted into development moneys for the psychiatric department. There has been a long-standing commitment to build and fund 16 functional mentally ill elderly beds from straightforward development moneys. It is clear that, far from the necessary money being provided, there is to be a severe shortfall in the provision of care for the elderly. There is to be only a partial replacement.

It is also important to understand that the creation of trusts is having a direct effect on the level of nursing care. I have been told by the trust that the quality of service when the elderly health care strategy is complete should not be affected. Almost all the staff being transferred to the newly built nursing homes are being downgraded, although at present they have an oral promise of the retention of existing commitments. That means that the skill mix in those new homes will be considerably less than that provided in the original hospital system.

We now know what happens when a new trust is created. We are told that it is a better way of providing health care, but the administration cost is increased by raising the wages of the tiny number of people at the top while the provision of health care for local people is reduced.

We should also discuss the damaging decisions that the Government are to announce tomorrow about the closure of teaching hospitals in London.

The Minister for Health (Dr. Brian Mawhinney)

Before the hon. Lady leaves Crewe, will she express pleasure at the fact that patient activity in Crewe increased by 9 per cent. last year?

Mrs. Dunwoody

I see people being run in and out of the services at great speed. One hon. Member said earlier that his wife had stayed in hospital for a week after having her baby. That is almost unique within medicare services and I hope that it was not a sign that she was suffering from any complications.

The way that people are now wheeled in and out of hospital services like sausages should be enough to cause even this Government to pause. I do not want the Minister to tell me that I should be delighted that patients are going in and out of hospital like people in a revolving door. I care about the quality of care that they receive and how many of them have to return to hospital for further treatment after they have been sent home too soon. I also care very much about what they find when they get home and how much care they receive there. The Minister does not talk about that at all.

In July last year I had what is termed a life-threatening illness and was taken into Barts hospital. I was there for some weeks and it became clear that the large ward on which I was being treated was entirely occupied by patients who came from Hackney, the City of London or the Barbican, where I have a home. Those in the ward were not patients who were not using their local health services.

Whereas I once might have said that there was a good case for dispensing a greater amount of expertise from London into other constituencies, I know that when the present Government shut centres of excellence they are not replaced. The same level of care is not provided outside the capital. All that happens is that those within the London district are deprived of services that are essential to them.

If the wholesale slaughter of the teaching hospitals is allowed to go ahead, there will be no provision for many people in the London region. The Government will not provide equal amounts of cash for Manchester, Liverpool and constituencies such as mine. All that they will do is cheat the population of London. Even the Government should be ashamed of that.

7.27 pm

Mr. David Atkinson (Bournemouth, East)

I congratulate my hon. Friend the Member for Falmouth and Camborne (Mr. Coe) on his excellent maiden speech. I pay tribute to his continuing work in health promotion with the Sports Council and the Health Education Authority.

Yesterday I had the pleasure of attending the official opening by the Princess Royal of phase 2 of the new Royal Bournemouth hospital in my constituency. On behalf of my constituents, I wish to thank my right hon. Friend the Secretary of State and her predecessors for making that superb new hospital a reality. It was a casualty of the cuts in the hospital building programme during the last Labour Government and was, therefore, long overdue.

The maternity unit in phase two anticipated the recommendation contained in the Select Committee report on maternity service in pioneering the establishment of a midwife-led facility for low-risk women. This has been a satisfactory outcome of the health authority's original intention to centralise all obstetric services at Poole hospital, which might have been convenient for the consultants, but was certainly not convenient for my constituents or for those of my hon. Friend the Member for Christchurch (Mr. Adley). I record our appreciation of our right hon. Friend the Member for Bristol, West (Mr. Waldegrave), who, as Secretary of State, ordered a re-think last year in response to our appeal to him. That has resulted in an acceptable compromise.

I congratulate the Government on pressing forward with their determination to make ours a healthier nation. Having implemented our strategy for a more efficient national health service, we are right to concentrate more than ever before on how we can avoid the need for health care in the first place. As my right hon. Friend the Secretary of State has said, tremendous progress has been made in recent years. Although it is right that the Opposition should point out where Britain lags behind, let us also give credit for the fact that we are leading the field in eliminating some of the seemingly incurable diseases of the past. Research is the key, and resources for it must remain adequate.

In the White Paper my right hon. Friend has selected five key areas for targeting; heart disease, cancer, mental illness, AIDS and accidents. These are the five horsemen of the modern apocalypse. Terrible as they all are, they have two things in common—they are mostly avoidable and they are mainly self-imposed. The Government must now build on that message.

A couple of years ago East Dorset community health council undertook "Survey 10,000" to discover consumers' views of health services and health promotion. It concluded that less than half of them were taking steps to improve their health. That is disappointing. The survey also concluded that of those who do seek advice, the majority will act on it. That is more encouraging.

Is there not more that can be done to encourage people to be more aware of their state of health by means of personal monitoring? I believe that there is. In July, a number of colleagues in the House responded to an invitation from IBM to become better aware of the use of information technology in our lives. Among the exhibits was a community based, touch-screen, public-access, health information system known as HealthPoint. It encourages the public to find out more about their state of health in a hundred different ways—diet, alcohol intake, smoking, AIDS, drug misuse and stress. For example, it can be placed in the waiting areas of hospitals and clinics, libraries, shopping centres, chemists and the workplace. If the Minister for Health is not aware of HealthPoint, I hope that he will make himself aware of it. It was developed by the university of Glasgow for his colleagues in the Scottish Office.

As the White Paper makes plain, heart disease followed by cancer present the greatest threat of premature death in Britain, not to mention ill health and disability for thousands. As my right hon. Friend said, we can do a great deal about both diseases and their avoidance. She rightly emphasised improved diet, and the growing emphasis on the risks of foodstuffs with lethal additives, sugars, salts and fats, is at last producing a consumer demand for more healthy alternatives, even in junk food like pizzas, burgers and potato crisps. This trend must be encouraged by education in schools, exhortation in campaigns and by clearer and compulsory labelling on foods. I hope that my right hon. Friend will keep up the pressure on our major food producers to find healthy alternatives to the more dangerous preservatives in food—emulsifiers in ice creams, for instance. I hope that they will respond even more positively to the clear, established link between saturated fats and heart disease.

Public attitudes and awareness of the need to take better care of one's health have improved in response to campaigns such as "Look after your heart". A recent Allied Dunbar survey showed that even more needs to be done to improve our fitness and to avoid heart disease. I was delighted by my right hon. Friend's initiative this week to promote health at work. The annual absenteeism cost of £5 billion suggests that a properly planned health promotion programme for staff would be incredibly cost-effective.

Many of us will be aware of the excellent organisation Fitness for Industry, run by our hon. Friend the Member for Dorset, West (Sir J. Spicer), who is also responsible for establishing the Westminster gymnasium. Looking around the House this evening I do not see too many colleagues who use the gym, and sad to say there are still many companies not even contemplating how they can convert some under-used or redundant corner of their premises into a fitness area where their employees can work out at lunch time and before and after work. The investment need not be great; a home multigym can cost only £300, a sum which unfortunately cannot be offset against company tax. I ask the Minister to urge the Treasury to make it allowable against tax. He should also urge the Health and Safety Executive to issue guidelines to employers on health at work.

Smoking remains the greatest single preventable cause of premature death in this country. The recent manifesto for action on smoking issued by the Health Education Authority has already been mentioned. Among my constituents, 13.7 per cent., or one in seven, die from smoking; 500 a year are admitted to hospital because of smoking, using 14 beds a day, at an annual cost of £664,000. I am encouraged, however, by the fact that these statistics are the fifth lowest in the country.

I welcome the strategy in the White Paper, especially its emphasis on no-smoking areas in public to combat the effects of passive smoking. Surely Roy Castle's successful treatment for lung cancer will bring home the dangers of smoky pubs and clubs. I remain convinced that the answer still lies in education, not in penal taxation, which does little to discourage the hardened smoking addict, who will make other sacrifices, usually at his family's expense. It would be helpful, however, if my right hon. Friend would confirm once and for all that there is absolute and conclusive evidence that smoking leads to lung cancer, which in turn leads to an agonising and premature death. Health warnings on cigarette packets should state that clearly.

Now that doctors can put smoking as a cause of death on death certificates without having to refer to a coroner, I hope that GPs will not hesitate to use this opportunity to improve the accuracy of statistics on tobacco-related deaths.

The White Paper describes HIV and AIDS as the greatest new threat to health this century. There is no alternative but to continue to promote ever safer sex and to emphasise more strongly than ever that it is anal intercourse that is largely responsible for AIDS. With neither vaccine nor cure in sight, prevention remains the essential message, and the governing bodies of schools have a heavy responsibility when deciding what additional sex education to provide under the national curriculum for 12 to 14-year-olds. Such education must be appropriate to the schools and must encourage young people—indeed, all of us—to talk more easily about the subject.

I conclude with one of the broader lessons that can be learnt from the alarming report earlier this year about the HIV-positive Birmingham man who infected at least three women and was blamed for having infected a fourth. There are certain conclusions to be drawn from the fact that those reports exposed a lifestyle which he and his friends pursued in their inner urban area—a lifestyle revolving around alcohol, football, videos and sex.

Mr. Deputy Speaker

Order.

7.38 pm

Miss Joan Lestor (Eccles)

I apologise for my voice. It would be wrong to blame it entirely on the fact that I am a victim of passive smoking in the Tea Room, a problem caused by those who are in turn the victims the tobacco advertising, but my hoarse voice is certainly linked to the smoke there. When one has a cold or a throat infection, the atmosphere in the Tea Room is bad for one's health. I just hope that my voice will last out this speech.

I want to concentrate on child health. Although that is referred to in the White Paper, children have been largely overlooked in the promotion of good eating habits and of health in general.

The target of reducing the number of children smoking has been mentioned, but from reading the report it is unclear how the Government will achieve that target without controlling the advertising of cigarettes. Other important issues, however, such as child nutrition, poverty and deprivation have hardly been tackled.

We could all read out our qualifications which entitle us to comment on such matters, as the Secretary of State did, but if we ignore the connection between child health and poverty and between bad housing and child health, we have learnt very little.

One in five of our children now live in poverty. That means that they are subject to great deprivation, as are their parents. Many of them live in bed-and-breakfast accommodation or in poor housing. Ministers' refusal to acknowledge the obvious link between child poverty and poor health is irresponsible and totally unacceptable.

It is self-evident that sub-standard housing leads to ill health. Similarly, families living in poverty will, of necessity, consume the sort of fat and sugar-loaded diet that easily staves off the pangs of hunger, but does nothing to build a healthy body. Anyone who has visited bed-and-breakfast accommodation knows that they offer no facilities for promoting a healthy diet.

The White Paper specifies targets for reducing adult obesity, which I welcome, but it says nothing about that problem in children. The seeds of obesity are sown in childhood. Anyone who has tried to change the pattern of eating established in childhood knows how difficult that is. People brought up in the 1930s filled a blank space with suet puddings, dumplings, cocoa and the like. They now suffer illnesses directly related to that diet.

We know better now, but, as my hon. Friend the Member for Halifax (Mrs. Mahon) has said, it is important to reinstate the nutritional standard of school meals. Many children no longer have a hot lunch and they have replaced it with sandwiches, sugary snacks or crisps. The school lunch is often the only hot meal available to children and they are now suffering nutritional deprivation—they will suffer illness throughout their adult lives as a result of that.

In the 1950s, graphs were kept of the comparative growth of rich and poor children. In those days children received free orange juice, school milk and proper school meals and the gap between the development of those children narrowed; now it is widening. For years the medical schools of Guy's and St. Thomas's—I hope that they will not be closed down—have carried out a joint study of the height and growth of children, which are strong indicators of health in childhood. The height differences between children in different social groups narrowed in the 1970s, but it grew wider in the 1980s.

Only last month Professor Walter Holland, one of this country's leading experts on community medicine, warned that British children were getting fatter and that a time bomb of obesity and disease was ticking away under them. He pointed out that the increase in children's weight, particularly among girls and children from the poorer economic groups, had not been commensurate with their increase in height. That weight gain is an important indicator of the likely health of those children when they grow up, especially in terms of the greater frequency with which they will suffer from arthritis, diabetes, heart disease and high blood pressure. As the hon. Member for Falmouth and Camborne (Mr. Coe) said in his maiden speech, we need to tackle the need for exercise in childhood. Too many children now go everywhere by car. I do not believe that the White Paper has addressed those warnings.

The Government also have a responsibility to protect children from the advertising of products that are damaging to their health. Earlier this year we debated the issue of tobacco advertising and I drew attention to the Benson and Hedges advert that featured a puffin—a symbol clearly identified by children because of Puffin books. Whatever the tobacco giants may claim, I am firmly convinced that they target under-age smokers. Indeed, they do so in order to replace the 300 addicted smokers who die from smoking-related diseases every day.

More than 450 youngsters start smoking in the United Kingdom every day and five out of six of them are under the age of 16. The Secretary of State rightly pointed out that the parents of many children who take up smoking are smokers. She implied that if adults stopped smoking, children would do likewise. That is why it is so important that we tackle the advertising of cigarettes, because children whose parents smoke see the attitude in their homes reinforced through advertising. If that were not so, those children would be less likely to smoke. Perceived attitudes have never been challenged and that is why the role of advertising is so important.

I am appalled that the former Prime Minister is now promoting tobacco in the third world. That is absolutely disgraceful and she should know better.

Janet Sackman was a young and healthy teenager who was chosen especially years ago to advertise Lucky Strike cigarettes—behind a waterfall, I think. By the age of 17, having been encouraged to smoke, she was hooked on tobacco and she has since developed lung and throat cancer. Who was that advertisement directed at? Not at hon. Members, but at teenagers like Janet. My hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) and I have a high percentage of constituents who are now dying from smoking-related diseases and we know that they were affected by that advertisement. One could cite many other such advertisements. We must recognise the problem caused by tobacco advertising.

Voluntary codes have been mentioned and the Secretary of State said that one cannot force people to do certain things. However, it is important to take issue with another problem connected with advertising—the inadequate controls over misleading advertisements of sugar-loaded foods and confectionery. Those products are often described as energy giving to young children and their parents. If the truth were told, they would be more accurately described as tooth rotting. It is important that the Government take a long, hard look at that issue against the backdrop of reduced dental care for children.

Local authorities are making cuts in school health programmes because of Government restrictions on spending. Our children are deluged with advertising that is often linked with unfortunate preconceptions. They believe that if they eat a particular food they will be able to perform to a particular standard in sports. That is an absolute disgrace.

The school nurse programme is underfunded and under threat. It has been brought to my notice that, in Gloucestershire, parents have received letters giving notice of the discontinuation of annual school dental check-ups. The reason for that decision was improvements in child dental health, but what brought about that improvement? It was the annual dental check-up. Children will now receive four check-ups throughout their school lives between the ages of four and 18. With national health service dentists to become as scarce as coal mines if the Government have their way, more families will find themselves unable to afford private treatment. If adults do not regularly visit the dentist, it is unlikely that their children will get into that habit. School dental check-ups are a vital safety net against the background of disintegrating public health care for our children.

How some of the targets relating to children in the White Paper, welcome though they are, will be reached is a mystery. The commitment to reduce pregnancies among under-16s by at least 50 per cent. by the year 2000 is welcome, but how can that be achieved without taking practical steps to prevent conception in the first place? Special attention must be given to that matter if we are to avoid more teenage pregnancies. The Birth Control Trust, for example, should be given more funding and support if we are to reduce the number of teenage pregnancies.

7.48 pm

Mr. Simon Coombs (Swindon)

I join my colleagues in congratulating my hon. Friend the Member for Falmouth and Camborne (Mr. Coe) on his excellent maiden speech. I also congratulate the hon. Member for Eccles (Miss Lestor) on surviving her 10 minutes. I thought that her voice became stronger as she went on, which shows that practice does help. That is an awful warning to all of us, is it not?

The White Paper is a move forward in health promotion, but I want to issue one or two warnings about it. I also disagreed with a couple of things that my right hon. Friend the Secretary of State said. I welcome the White Paper and all that went before it because they have created the framework for health promotion. It is right to pay tribute to the progress that has been made in relation to GP contracts and the improvement in targets in such things as cervical smears and child immunisation. Those are welcome steps in the right direction, but we still have serious problems in this country.

The first problem is coronary heart disease. This week I put a question to a Minister at the Welsh Office, and received the information that in Wales the number of deaths from coronary heart disease had fallen from 345 to 331 per 100,000 in the past 11 years. That is progress, but it is slow, and it is not speedy enough to satisfy those hon. Members who feel strongly about such issues.

In almost 10 years since the publication of the Committee on Medical Aspects of Food Policy report there has been little progress in reducing our population's intake of saturated fats. There has also been too little progress on increasing the amount of fibre in the diet through eating fruit and vegetables. I do not join Opposition Members in saying that it is simply a matter of social class or is due to whether people are richer or poorer: it is up to people to make choices, and they can make them irrespective of their income or that of their families.

Another problem is plasma cholesterol. That is often a genetic feature, but we can all do something about it. A 10 per cent. reduction in plasma cholesterol could lead to a 20 per cent. reduction in premature coronary heart disease. There are ways in which cholesterol can be reduced, even by people who may have a genetic tendency towards it. That is of crucial importance. I hope that my hon. Friend will tell us at the end of the debate when the Government intend to respond to the Standing Medical Advisory Committee's proposals on cholesterol testing. The House will be interested to know when we can expect progress in that direction.

Like every other Member who has spoken, I must mention smoking. I am one Conservative Member who feels that we must insist that the European Community does something about the scandalous subsidising of tobacco crops throughout the Community, which is costing its taxpayers £1 billion per year. We must also consider the vexed question of tobacco advertising. Having lost a parent from lung cancer, I feel that we must take any step that will reduce people's tendency to smoke and to reduce the number of passive and active smokers.

Clearly the Government have set a challenging target. Why lose any opportunity to reach that target? When the Smee report is published next week, I am sure that it will show that in countries which have banned all advertising—not merely television advertisements—that has helped to reduce smoking. Let us follow suit and not be too worried by arguments about freedom. It will still be up to people to decide whether they smoke. For heaven's sake, why do we want to encourage them in any way?

On health education, we must deal with nutrition education in schools. That has not been mentioned in the debate so far. I am not happy that the nutritional advice made available through home economics within the national curriculum is sufficient to encourage young people into healthy eating and cooking when they become responsible for families. We must ask the Minister to talk to Ministers at the Department for Education—not merely through a Cabinet Committee—to impress on them the need to ensure that health economics teaching includes advice on diet and nutrition. I hope that my hon. Friend the Minister will feel able to respond to that at the end of the debate.

I welcome the healthy schools project, and I hope that it will include some of the suggestions from the school meals campaign. It is not good enough that while some counties, such as mine, make every effort to encourage healthy eating in schools, in others the pizza generation has taken over, almost to the exclusion of everything else. The pizza van waits outside the school gates every lunchtime for its ready victims to come forth. We have to insist on national standards in something as important as school meals.

I hope that my hon. Friend the Minister will tell the House when we can expect the Government to propose full nutritional labelling. There has been much consideration and involvement with the European Community on that subject: now we need action. A great deal of progress is being made. It is true to say that industry is now more aware of its responsibilities for the diet of the nation.

The Food and Health Forum—the all-party group in the House which I have the honour to chair—has received presentations from organisations as diverse as the National Farmers Union and the Food and Drink Federation and they all accept that they have responsibilities to improve the nation's diet. That is important and should be encouraged by Members on both sides of the House.

Finally, the targets in the report may not look tough to some hon. Members but they will be hard to achieve because, human nature being what it is, people will resist blandishments, encouragement, education and incentives. There will always be those who say, "We know best" and "My grandmother lived to be 90 and she smoked 40 a day, so I can do it too." They may be right, but that does not alter the fact that everyone who smokes has a greater chance of dying a premature and agonising death. That fact is incontrovertible. We must tell people who have a sweet tooth and who enjoy a rich fatty diet that they are taking risks with their health and that they could avoid those risks if they chose to do so. However, we all know that many of them will choose to ignore whatever advice is given. We must press on, and we must tell the Government that it will not be easy to reach those targets. Too many people will say, "We are immortal—it will never happen to us."

Education will be important. Whether it is provided by the health education authority or by health education units within the health authorities, it is expensive and it will have to be paid for. My hon. Friend will have to deal with the problem of where that money is to come from. We can improve the lifestyle of all the people in this country, if we are prepared to do so, but let us not pretend that the White Paper is anything more than one step along a road which will be difficult and challenging, and which will require sacrifices by everyone in the country, whether they are smokers or those who indulge in the various dietary inadequacies which disfigure our population to far too great an extent.

7.58 pm

Mr. John Hutton (Barrow and Furness)

Many Labour Members, including my hon. Friends the Members for Sheffield, Brightside (Mr. Blunkett) and for Eccles (Miss Lestor), have expressed our reservations about a health promotion strategy that fails to give proper attention to significant factors such as unemployment, economic deprivation and poor housing conditions.

While the Secretary of State for Health has sought to develop a strategy to improve the health of the nation, other policies are being developed by different Government Departments which are having the opposite effect on that strategy. I am thinking of the Government's economic and industrial policies, which are creating an inexorable rise in unemployment, of the Government's employment policies, which are encouraging low and poverty pay, and of their housing policies, which are creating ever-increasing tension and stress in the housing stock, especially in public sector housing.

I do not intend to dwell on that aspect of our reservations about the Government's health strategy, although I must say a little about what is happening in my constituency. In two years Barrow and Furness has lost 8,000 jobs. Every week, when I hold my advice surgeries, I see growing signs of increasing economic deprivation. More and more of my constituents are being forced on to income support and benefit, and I am deeply concerned about what is happening to the health of my constituents. I know that in the coming years there will be many other constituencies throughout the country where the Government's policies will have an effect on the health of many thousands of people.

I wish to concentrate on three issues that arise from the White Paper which bear on the Government's policies on accident prevention, reducing the incidence rate of cancer and dealing with mental illness.

I ask the Government to consider the role of home safety committees within their strategy on accident prevention. I read the White Paper and I could not find one reference to the committees. I assume that that is an oversight by the Government and not the result of their pathological aversion to anything and everything that is provided by local authorities.

Home safety committees are administered by local councils. They bring together local NHS agencies, emergency services, voluntary organisations and trading standard officers. They do an excellent job and the Government should examine their work carefully with a view to putting it on a statutory basis. In taking that course there would be resource implications for the Government, and perhaps that is why there is no reference to the committees in the White Paper.

Perhaps the Government, and especially the Minister for Health, will have to consult Ministers in other Departments. I hope that the Minister will be able to give us an assurance that he will at least consider my suggestion. Home safety committees, and especially the one in my constituency, are doing an excellent job.

It is important that action is taken across a range of areas to tackle the incidence of cancer. Many of my hon. Friends—I am glad that there are Conservative Members who support the view—believe that the Government cannot continue to avoid taking further measures to prevent tobacco companies advertising their products. Despite what is often said by these companies, their advertising is clearly and blatantly aimed at young people and at recruiting new smokers. That is a disgrace.

I regret that the White Paper takes a rather disingenuous approach to tobacco advertising. As a result, the Government's targets for reducing the incidence of lung cancer and other smoking-related illnesses appear to be hopelessly optimistic. A ban on advertising should be at the top of the Government's agenda and not wrapped up in the weasel words that are all that we see in the White Paper.

In the treatment of cancer, excellent work is being done by the hospice movement in providing palliative care for those who are dying from the disease. I mention especially the work of St. Mary's hospice in Ulverston in my constituency. It is a small hospice—there are only six beds—but it provides a vital home care service and a drop-in support service. Demand for the services that it provides constantly outstrips availability. The hospice has to rely heavily on voluntary contributions. Its budget is about £500,000, about 83 per cent. of which comes from its own fund-raising efforts. That is a remarkable tribute to the people of Furness and of the south lakes area.

The hospice receives no direct funding from the South Cumbria district health authority, but I am glad to say that it benefits from the Government's allocation to regional health authorities. Of course, that funding is not guaranteed beyond this year. I hope that the Government will extend their support to the hospice movement in general and keep under constant review the mechanisms through which health authority funding is distributed to the hospices.

I would like to have seen greater emphasis in another area of the Government's proposals, and that is on a recognition of the value and role of proper bereavement services in promoting the health of the nation. Those who, like myself, have experienced the immense grief that is caused by the death of a child will know how debilitating the sense of loss can be. There can be a real threat to the physical and mental health of those who are mourning the loss of a loved one.

I shall never forget when my second son, Jonathan, died 10 years ago. I was told by caring professionals in the NHS that I was young and that my family and I could look forward to having more children. I was told that, in effect, there was nothing to worry about. That was not the result of callous indifference on the part of the profession. I believe that it was the result of a lack of efficient and proper training. I want the Minister and the Government to recognise that this is an area in which the expertise of the hospice movement can and should be central to developing a national response and strategy. I hope that the Minister will be able this evening to say something about the Government's view of bereavement services as part of their target of improving the mental health of the nation.

As I have said, I hope that the Government will be able to respond to what I have said about the role of home safety committees and bereavement services. I have reason to believe that I should be less than optimistic that they will begin to address the problem of tobacco advertising. Unless they do so, however, their credentials in promoting the health of the nation will be seriously compromised.

8.7 pm

Dr. Liam Fox (Woodspring)

I begin by congratulating the Government on bringing forward for the first time a real health strategy. For too long debates in the House have focused on funding mechanisms and developing the correct mechanisms to achieve better value for money. At last we have started to measure output in our health care system. For too long also we have measured the quality of health provision by what we put into the system. That is rather like the shopper who measures a good day's shopping by the amount of money that has been spent rather than on what has been brought home. The White Paper goes some way at least towards setting real targets in trying to achieve good value for money and the correct outcome in terms of health care.

We must congratulate the Government where credit is due on having the lowest infant mortality rate of all time, the lowest post neo-natal mortality rate, on having brought in the new haemophilus influenza B vaccine and the new typhoid vaccine and, I hope, increasing the take-up of them. These are real improvements in our health care. I wish that sometimes the Labour party would give us, the Government, a little credit when we bring forward real improvements. Constant sniping—pretending that nothing good is happening in the health service—is bad for the entire debate and makes the climate for debate all the more difficult.

I have a particular interest in the primary care sector, because I was a general practitioner until the general election. Most of my hospital training was in the east end—the poorer part of Glasgow. For a short time I worked in Harlesden, in Brent. I was appalled there at the inequality within primary care services. In inner-city London, there were general practitioners with no appointment service and no proper system of record keeping. In some instances, there was no running hot water. At the same time and in the same system, but in another part of the United Kingdom, there were general practitioners who, with the same funding system, were providing plush waiting rooms, an excellent appointment system, health care clinics and preventive measures. Surely that is unacceptable in a publicly funded service.

What do we do? The Government responded by bringing in the general practitioner contract to try, for the first time, to establish a minimum acceptable standard of care. What did we get? The Labour party was up in arms. It told the people that the health service was about to fall apart. The British Medical Association told us that it would not be able to carry out the preventive measures that it had been undertaking until that moment.

I ask the House to look at the record. We have seen a tremendous increase in the take-up of immunisation. Preventive measures have been taken in the form of hypertension, diabetic and asthmatic clinics. These have been provided within the health service, but perhaps there have not been enough of them.

The carrot has worked rather well. It has brought forward many more services. It worries me, however, that general practitioners, especially when there is a high patient turnover, can still make a good and happy living without having to bring in some of the services that are detailed in the contract.

I would be happier if the Government considered carrying something of a stick. Perhaps we could have a general practitioner inspectorate to focus especially on inner-city practices. We have made tremendous advances, but there are still some places and areas that leave something to be desired.

We shall also have to consider the role of medical education, especially in view of the community care programme. For example, general practitioners do not have much training in dealing with mentally handicapped people or mental illness. I had six months' training in psychiatry as part of my general practice training, but that was not compulsory.

It is possible to be a general practitioner in Britain with no experience in psychiatry apart from a couple of weeks' training as an undergraduate. We must consider that if we are serious about obtaining the proper treatment for mental illness in order to attain our targets. If we are to deal adequately with potential suicides, we must know how to spot them. If we are to deal adequately with post-natal depression, we must know which patients are vulnerable, and that requires good medical skill.

The most attractive feature of the White Paper is the Government's clear commitment to a multi-departmental approach. It is far too simplistic to say that poverty causes this and homelessness causes that. Public health is multi-factorial. We know that asthma is worsened by too many vehicle emissions. All the evidence points to that. But that is the consequence not of a poor society but of an affluent society with too many motor cars on the roads. Much heart disease is due to people having too sedentary a life style because there is too much transport so that they do not do enough walking. Again, that is a problem of affluence. All I ask is that the House does not take too simplistic a view in dealing with such matters.

Of course poverty is a factor. All epidemiological evidence suggests that there is something in that, but all we hear from the Opposition is poverty, poverty, poverty—la, la, la, always on the one note, never accepting the complexity of the issues. Not once did the Opposition mention that. They are always hitting on the one strand. That does not advance the debate one little bit. It is just boring for Conservative Members.

There is one other problem in how we are to move forward. We know that we will have to work within public spending constraints and we know that medical science will continue to demand ever more. Therefore, irrespective of national wealth, there will be a genuine gap between what we can afford to buy and what medical science can provide. I ask my hon. Friend the Minister tonight to question some of our priorities.

For example, is it ethically justifiable to spend £3,000 a time reversing vasectomies that patients have chosen to have on the NHS when we have a shortage of coronary care beds? Should we spend millions of pounds removing tattoos when we have other priorities in the health service? Those are genuine questions which will have to be addressed.

I am sorry that, largely because Opposition Members take such a simplistic view, those issues have not been aired as they should have been today. I hope that my hon. Friend will consider all of them. The Government are to be commended for a courageous White Paper. It is a welcome start.

8.12 pm

Ms. Angela Eagle (Wallasey)

I crave the indulgence of the House at the beginning of my speech as I am suffering from an affliction similar to that of my hon. Friend the Member for Eccles (Miss Lestor). I only hope that my voice lasts as long as hers did.

I was particularly moved by what my hon. Friend the Member for Barrow and Furness (Mr. Hutton) had to say about bereavement. Having suffered the loss of a parent, I too believe that there are large gaps in the services currently offered in that area, which need addressing urgently.

It is just possible to believe that we have a Government who care about the nation's health. I commend the Government for having a strategy, however inadequate, and for finally deciding to introduce health targets. Any target, even the wrong one, is better than no target at all. That is the faint praise that the Government will get from me tonight.

Leaving aside the alarming omissions of analysis in the White Paper which render its prescriptions flawed and problematical, and leaving aside the Government's obsession with individualism and their refusal to admit that good health relies on far more than a responsible attitude to one's own health, important though it is, and even forgetting the Government's obsession with market forces as a panacea for all problems—we heard a great deal earlier about the so-called centrally planned socialist method of delivering health care in Britain, which served us well for many years—what we have not heard about is the fundamental problems in delivering health care services according to a market ethos.

They are there in theory, in that the market fails for health care because of externalities, imperfect information and supplier-induced demand. The market fails in neo-classical economic theory and it fails in experience. We need only look at the parlous state of the American health care system, which is the most privatised and market-oriented in the world, to prove the truth of that contention.

Even with those gaps, we might suspend disbelief and give the Government the benefit of the doubt, but the omission of the issue of social inequalities, which has rightly been much commented upon by my hon. Friends, finds them out. There can be no realistic or serious preventive health care strategy without an analysis of social inequality, poverty and its ill effects, unemployment and its ill effects, bad housing and its ill effects and—this will be an increasing issue as the market-oriented reforms come through—access to health care for all and increases in charges which deny access and the ill effects that that can have in a preventive health care setting.

It is not my intention to show any disrespect for the often important work that is being done in that area by the regional health authorities, the family practitioner committees, associations, district health authorities and general practitioners, but they cannot be expected to make a good case and fight ill health with one hand tied behind their back.

How can we take seriously any attempt to improve the nation's health which makes no mention, in 125 extremely glossy pages, of poverty and of the proven links between unemployment and ill health and between bad housing and ill health?

If the World Health Organisation's report was an inspiration to the White Paper, why on earth did it take the Government more than 10 years to get around to introducing the first health targets? The WHO initiative was launched in 1978, and it was not until 1988 that the Secretary of State for Wales introduced the first targets in Britain.

Why, if the WHO was such an inspiration to the White Paper, have the Government ignored the first target of that initiative, which aims to reduce inequalities both within countries and between countries in income and social provision? Instead of acknowledging that well established connection, the Government seem to have omitted to mention it as often as possible, presumably in the hope that no one would notice. As a fall-back position, they have come up with lame excuses for taking no account of it.

When the Green Paper was published, the then Secretary of State, the right hon. Member for Bristol, West (Mr. Waldegrave), said that the Government did not believe that there was any panacea either in terms of a full explanation or a single action which would eradicate the problem of the ill effects of social inequalities. But the Government have, by act of their own policies, made social inequalities worse, and that has exacerbated the problems of ill health in some of those pockets of poverty that those of us who come from constituencies where such poverty exists see in our surgeries day in, day out. The Government have systematically and deliberately lowered, worsened, destroyed social provision for millions of Britain's people, and it is compromising their health and well-being even as we speak.

The Government have created, by design or incompetence—one can take one's pick—mass poverty on a scale not experienced since the 1930s. The Government have created, by design or incompetence, two recessions in 12 years. They have created mass unemployment, and even as we debate they are planning to destroy the jobs of 31,000 miners and 70,000 in the service industries with one more swing of the axe. As Tory recession turns to slump, it is worth remembering that the Government's policies have worsened social inequality. It follows that they could better achieve equality with the right policies, and thereby improve the nation's health.

The correlation between inequality and health is well established. Office of Population Censuses and Survey figures on occupational class and mortality demonstrate a widening gap between the death rates of manual and non-manual workers, with the unemployed doing worse still. In fact, mortality rates are worse among the poor, who also suffer a higher prevalence of long-standing illness. They have shorter lives and suffer poorer health.

Earlier, the Secretary of State quoted the chief medical officer and refused to allow me to intervene, with the valedictory statement of the previous chief medical officer: Analysis of the major advances in health which have occurred since Sir John Simon's first report show that these have been more often with improvements in social circumstances than with medical advances. Thus, where people are in a position to exercise greater choice in their housing, environment, employment, leisure activity, and consumption generally, this has tended to be beneficial to their health. By contrast, those not able to exercise greater choice because of low income, lack of education or lack of capacity to take the initiative tend to suffer more ill health. Research shows that life expectancy is closer correlated to a distribution of income. That was borne out by experience during the second world war, when civilian life expectancy increased two to three times, despite the Luftwaffe and the blitz. One of the features of wartime Britain was that income was rapidly redistributed, and many ate better on rations than they ever dreamed of doing in the recession-ravaged 1930s.

In a recent article in the British Medical Journal, Tony Delano wrote that, as Britain had become much less equal, the mortality of men aged between 15 and 45 had once again begun to increase—and that excludes death from AIDS. Why is there no Government recognition of those facts, much less any attempt in the White Paper to do anything about them? We have a clue to a real and meaningful preventive health care programme that would deal with fundamental issues, rather than dishonestly tinker around the edges. I plead with the Government to make social inequality a key area and to do something about it.

8.22 pm

Mr. Michael Trend (Windsor and Maidenhead)

A better state of health is a laudable objective, and for the national health service to be required to focus as much on that as on health care is all to the good. I commend the good sense that informs the views in "The Health of the Nation", but I want to voice a few concerns that struck me as I read it.

It will be difficult to strike the right balance between that which the Government, and they alone, can do and that which, to quote the introduction by my right hon. Friend the Secretary of State, other organisations and agencies need to do and, finally, individuals and families themselves must contribute if the strategy is to succeed. We are all concerned by the prospect of illness. One press commentator recently said that serious illness and indeed death are regrettable misfortunes that interrupt the optimistic planning of our lives, and so are best avoided. Quite so. The question is: how to avoid them? One of the White Paper's answers is to evolve an overall strategy with targets to be met.

If I were a doctor and someone came to me suffering from a "strategy", I would advise recourse to a bottle of aspirin. If the patient later returned complaining of "targets", I would put him on Mogadon.

Some may think that I am only trying to make fun of modern buzz words and that I should bravely swallow the prescribed nostrums and retire to bed. That is far from the case. My concern is that "The Health of the Nation" has a tendency to follow the five-year-plan-school-of-government, beloved by those highly centralised socialist economies that are now so out of fashion. In those cases, they were mainly trying to plan for tractors and other inanimate articles. They had little success. How much more difficult it is to plan for people.

We are not, thank heavens, a highly centralised socialist country where the whim of the few dictates the fate of the many, but the central dilemma for the Government lies in that area.

Let us imagine for a moment that the suicide rate does not drop by 15 per cent. by the year 2000—or that the rate of conceptions among under-16s is not halved by the year 2000. Who will be to blame? The answer is easy. The poor old Government will cop it, as usual.

On the one hand, the Government have very limited powers to affect the targets that they have chosen—other than those which seem likely to be achieved through momentum already in the figures. On the other hand, the Government have put themselves in a position where they will get the blame if the targets are not met. They cannot win either way, whichever party is in power in the year 2000—and of course it will be the Conservative party.

I would like a much stronger emphasis to be placed on the proposition that individuals are free to make their own decisions and that they will often involve moral choices—such as whether or not to bring a child into the world without the benefit of marriage.

The great growth in the number of teenage pregnancies has occurred at a time when sex education has been freely and widely available in schools. We all know that figures can be made to serve many purposes in circumstances such as this, but the present evidence will not allow the proposition that more sex education equals fewer teenage pregnancies. The reasons for such a development lie elsewhere.

What is most needed is a stronger emphasis on the individual and more stress on the limits of the Government and their proper functions. Health education is all-important. Above all, people should be taught to look after themselves, with minimum interference from the state.

I remind the House of Disraeli's great 1872 Manchester speech, when he advanced the motto, "Sanitas, sanitaturn, omnia sanitas." He, too, was talking about health but his central observation was: The great object is to be practical. He was after clean air and water and better drains. Those are practical challenges to which Governments can rise. Legislating for individual behaviour is, however, a very different matter.

Sensible people will behave sensibly about their health, and when they do not they will know that they are not behaving sensibly—and will only persist in a course of action—say, smoking—in full knowledge of their actions. They will accept the responsibility for such action.

The key is to make a nation of sensible people. The House will forgive me if I postpone giving my prescription for achieving that great objective until another time. I will only say that it is not very sensible for the Government to offer some of the hostages to fortune that it has in the overall strategy of the White Paper, with its specific targets.

I do not believe that we must insist that people adopt a certain approved way of living. That was the argument of the theologians of the middle ages—that the Church was so important that people must be "forced to come in." It may well be that health has become the new religion, but the Church has had to face up to the enlightenment—and health care professionals must also accept that the supreme idea of the freedom of the individual should only be circumscribed if one individual's actions damage the rights of another. It is in this context that I turn to the question of tobacco advertising. Nothing is more important than that people should be allowed to make their own decisions, as far as possible.

Does giving the right to one person to decide whether to smoke one brand of cigarette or another infringe the right of any other person? I think not. In certain cases I would approve of restricting advertising in places or in contexts where the young would be particularly likely to see it. In general, I believe that a ban on tobacco advertising would be an infringement of the rights of the adult individual and the companies that manufacture—however much one might disapprove of it—a legal commodity.

All sides in the debate are asking for what is called nowadays a level playing field. None of them means that. They all want to see their own position triumph, however bumpy the field may be. That is particularly true when the European element enters into the argument.

Why on earth should tobacco advertising be a matter for the European Community? The issue should be dealt with by national Governments. Here is a clear case of subsidiarity—unless one is one of those people who want to change British policy through the Brussels back door.

What of those European Governments who have banned tobacco advertising, while themselves remaining substantial owners of tobacco industries? That is a bogus position to which no British Government should seek to tie themselves.

Moreover, we have been reminded that, between 1976 and 1986, the incidence of smoking in the United Kingdom fell by 29 per cent.—a reduction second only, in Europe, to that in the Netherlands. As the Secretary of State pointed out, the Netherlands, like the United Kingdom, favours a voluntary system of controls on tobacco advertising.

We have also heard that the United Kingdom has, after Denmark and Ireland, the most expensive cigarettes in Europe; but in Spain, where a total advertising ban is proposed, a packet of 20 cigarettes costs only about 40p. That contrasts with the position in our country, where the price mechanism is fixed strongly against the producers. Britain, furthermore, is one of only five European countries that do not grow the dreaded weed. Those that grow it enjoy subsidies under the common agricultural policy, which I regard as entirely unacceptable.

Where is the sense in it? I ask the question especially of those who support the notion that we should ban tobacco advertising in this country under the aegis of the European Community. It is also worth noting that the four EC countries that have nationalised tobacco industries—together with Greece—have the lowest-priced cigarettes in the Common Market. As the Secretary of State said, it would be ludicrous for Britain to take lessons from other countries whose records on the reduction of smoking leave so much to be desired.

Advocates of a ban on tobacco advertising should not lose sight of the wider issues, such as the freedom of the individual and the commercial freedom of speech of companies in the legitimate pursuit of their business. I hope that my party will resist the siren voices that demand that we turn our backs on the advanced and effective voluntary agreement to restrict advertising that we currently operate. I think that it can be said that the Opposition parties see some blatant partisan advantages in that.

For many years now, Conservatives have argued that we should roll back the limits of the state. We have talked about the nanny state, and about how we wish to be rid of nanny. I share that view, especially because I believe that the only eventual loser in the nanny state is the state itself. Let us be more careful about the ends for which we choose to aim, and let us limit ourselves in the means that we try to deploy. Nanny belongs in the nursery of life, not in the corridors of power.

Having said that, however, I must end by observing that, if we must have a nanny, I can think of none more pleasant or acceptable than the present Secretary of State.

8.32 pm

Mr. John Denham (Southampton, Itchen)

The Secretary of State told us of the success—as she put it—of the health service reforms, and advised us to lift our sights above the structural issues in the service; but none of the objectives of the White Paper can be met unless the resources of the health service are spent effectively and the service managed efficiently. I wish to raise a structural issue. I believe that I have every reason to say that money is not being spent effectively and that, both as a cause and as a consequence, management is not efficient.

The day after the House rose for the summer recess, the district auditor published a report on the regional information systems plan, RISP, which was abandoned by Wessex regional health authority in 1990. Between 1982 and 1990, £43 million was spent on the now abandoned computer system. Money was wasted on a vast scale: the exact amount is not known, but the current general manager has estimated the losses at a minimum of £20 million.

That loss is staggering, and the lost opportunity to treat patients or to prevent illness is immense. A BBC South investigation broadcast earlier this evening showed surgeons relying on an Army field hospital at Southampton general hospital because no money was available to repair the roof; yet £20 million has been wasted on a computer system. The district auditor's report revealed mismanagement and suspected malpractice on a massive scale. In 1983, health authority members were told that the scheme would cost £26 million. The officers believed that it would cost £75 million, but did not tell the members because it was apparently deemed politically unacceptable.

In circumstances which are still unexplained, a £21 million contract was awarded to a consortium led by Andersons and involving IBM, although its proposal had originally been ranked fourth in order of merit. The decision was made at an inquorate meeting; members were not told of disagreements among officers; and, according to the district auditor, there was an unacceptable conflict of interest, in that one of the tenderers to whom the contract was eventually awarded would appear to have had access to confidential information concerning rival bids". I note that there was a member of the IBM board on Wessex regional health authority for much of the 1980s.

At a later stage, £3.3 million was spent on an IBM computer which was not needed. The opportunity to cancel the contract and minimise losses was missed, and the computer sat unused in a Slough warehouse for 18 months. Some Wessex computing functions were transferred to a new company, Wessex Integrated Systems. According to the auditor, all the major decisions were taken by a small group of officers (one of whom was intended to become a director of the company) who were in turn reliant upon the advice of the consultants who later benefited from the decision. Other computing work was transferred to a company involving AT and T Istel. It is now the subject of police investigations.

Many other failures of management and budgetary control are detailed. For instance, there was over-reliance on consultants—some costing £14,000 per month—and at least £7.7 million being spent on consultancy fees for a project that was subsequently abandoned. There have been conflicts of interest. In one case, an officer advised on the appointment of consultants without tender; he then resigned, and came back as a consultant to the firm that had been offered the contract. Later, a consultant seconded from IBM advised against the cancellation of the order for the IBM computer that was not needed.

I have touched on just some of the key problems revealed by the district auditor's report. The RISP disaster is a fully fledged scandal in its own right, but it throws up many more questions. Have such problems been endemic in the national health service? Are proper systems now in place to prevent abuse and mismanagement? Does the NHS ensure that the painful lessons learnt in one place are quickly transmitted to other parts of the service? I believe that the problems have been endemic, and that there is still no evidence of the existence of effective systems of accountability. I believe that the service is still failing to learn the lessons of past disasters.

As a result, not only is money being wasted, but there is a question mark over the information systems on which the Government's own internal market policies depend. There are many other cases of failed projects and poor financial control. A critical audit report is expected any day now on the £2.3 million Healthtrac system in the west midlands. We know that computer systems have been scrapped at Guy's hospital.

It is alarming to note that every major computer failure that has come to light in the health service has done so not because of the strength of the internal audit procedures but because the story has leaked out to the media, and an investigation has subsequently taken place. If magazines such as Computer Weekly had not covered such stories, we would not know about them, and we would not know how much money had been wasted. We must ask how many other high-tech skeletons are in the cupboard.

In 1990, the National Audit Office report on managing computer projects in the NHS examined the RISP project, but failed completely to identify the damning evidence now available in the district auditor's reports. The NAO report said that the NHS needed between 4,000 and 5,000 skilled information technology staff to manage its information strategy, but that only 2,000 were in place. As a result, expenditure on consultancy firms was running at £50 million per year. Has there been an improvement? Has there been any monitoring of that objective?

The same report called for the training of 800,000 NHS staff in the use of IT systems. Has that been achieved? The Government promised to publish an information strategy for the NHS in April 1991. As far as the House of Commons Library and the Department of Health have been able to tell me in the past few days, there are still no signs of it, and no signs of the resources that are needed to make such a strategy work.

How much money is being spent on computer hardware and software? According to the Official Report, expenditure in England in 1990–91 was £110 million—surely a large proportion of the whole. According to a commercial survey by Romtec, hospitals alone are planning to spend £300 million on hospital information support systems in the coming year. A report by the European Marketing Association puts the figure for all IT expenditure, excluding telecommunications, at £800 million.

Who is right? Do the Government know? According to the Official Report, the Government do not collect data on computer expenditure by trust hospitals. The hospital information support systems project was supposed to computerise hospitals at a cost of £2 million to £3 million each. It has turned out to be much more complicated and expensive. Mr. Giorgianni of the computer company HBO is quoted as saying that the Department of Health never put a fence around the projects. The concept has grown from a lizard to a dinosaur. One project, in Nottingham, is costing £8.5 million.

Finally, there is a fundamental question about the IT strategy itself. Confusing mixtures of megaschemes and smaller schemes are being pursued. Nobody has had the courage to enforce standards in information systems across the health service to ensure that one machine and one system can talk to another machine or another system. It is likely that many millions of pounds have been wasted as a direct result of NHS reforms, as systems developed for a different style of management in the health service have had to be scrapped in order to respond to the new internal market reforms.

Without effective information systems, the internal market certainly cannot work. This is not a technical management issue. It has its roots in the pace of change of ideologically driven reforms. That change has taken place without an attempt having been made to assess the resources needed, to provide them, or to monitor their use effectively. For all their talk of efficiency, the Government have created a climate of irresponsible management, which has been exploited by the computer industry. That should now be investigated. I have today written to the Chairman of the Public Accounts Committee urging him to do just that.

In 1987 Mr. John Garfield, consultant neurosurgeon and chairman of the regional medical advisory committee, wrote to the regional general manager of Wessex regional health authority saying that his committee considered that the past and projected expenditure on RISP will jeopardise services for direct patient care. That warning was ignored and £43 million was spent, a large part of which was wasted. If a similar letter were written today by somebody who was concerned about patient care, would it make any difference? Would that person be listened to, any more than were the doctors in Wessex when they warned of a disaster which has led to the pouring of taxpayers' and patients' money down the drain?

8.42 pm

Mr. Nigel Evans (Ribble Valley)

I welcome the White Paper. In doing so, I intend to approach the debate from a different angle. I declare an interest as a retailer. I sell foods that we eat and cigarettes that some people—a minority of people in this country—smoke. I have been involved in my family's retail business since I was tall enough and smart enough to operate a till. I got to know how consumers think. The White Paper emphasises health promotion and recognises the fact that the health of the nation is the wealth of the nation—that people are our greatest national asset and should be encouraged to look after themselves.

A gentleman in his eighties told me that, had he known that he was going to live for so long, he would have looked after himself better when he was younger. Is not that ever the case? We expect to live longer now, so we ought to look at how we can improve the quality of our lives. A key target in the White Paper is the reduction of coronary heart disease and strokes, the single biggest cause of premature deaths in Britain in 1991. Another aim is to reduce obesity, a condition to which some hon. Members would have to plead guilty, although when I say that I am careful not to look at any individual Member. Another good aim is to reduce the energy derived from saturated fatty acids and fat.

Alongside that, however, is the danger that, in providing the information necessary for consumers to make the right choices, the whole issue will be over-simplified—that it will become a question of good foods versus bad foods, when all that is really needed is a balanced diet. A Mars a day helps us to work, rest and play, but 20 Mars a day would probably kill us after a while. We need to strike the right balance. The clear labelling of goods should not be so over-simplified that it is reduced to decribing foods as good or bad. All that the consumer needs is more information.

There appear to be many experts giving their advice on certain food products, advice that is contradictory and that ends up confusing the consumer. More education is needed in our schools. School dinners have been mentioned time and time again. I hope that they will receive the attention they deserve. We need to balance our food requirements, not directives that simply state that chips are bad for us and yoghurts are good for us: an excess of either would probably damage us. Schools have to be the key to a healthy future.

The pilot assessment schemes mentioned in the White Paper are essential if we are to monitor the progress that is made. If those schemes work, we shall need to widen them immediately. That goes along with good sports exercise, which was mentioned in the excellent maiden speech by my hon. Friend the Member for Falmouth and Camborne (Mr. Coe). We look forward to hearing from him on many occasions.

The fact that cigarette consumption has declined is to be welcomed. That decline has taken place during the last 13 years of Conservative government, and now accounts for less than 35 per cent. of my turnover, whereas in the 1960s it was nearer to 60 per cent. Cigarettes are a price-sensitive product. Taxation levels have worked. Cigarettes cost 41p for 20 in Spain—a ridiculous price. However, as I believe in subsidiarity, I have to say that they must get on with it. If one refers to subsidiarity though, one must also consider the £1 billion subsidy to tobacco growers throughout Europe. That is insane, for it affects each and every one of us.

I do not believe that advertising of tobacco products, in their regulated form, or tobacco sponsorship leads people to smoke. It may lead to some brand switching. I do not think, however, that anybody who watches the Embassy-sponsored snooker championship gets out of his seat at the end of it to go and buy 20 Regal, or that anybody who reads the message from Reg on our billboards—that moron-type character who is leading the Regal advertising campaign—will be enticed to smoke cigarettes. The message underneath the advertisement, that smoking kills, would persuade me not to smoke.

We must adopt a balanced approach. If we do away with the billboard advertisements, we also do away with advertisements that tell people that smoking kills. We want education, not legislation. Retail businesses that rely for their core profit on tobacco products must be few and far between. I suggest that they should do what we have done—diversify as much as they possibly can away from tobacco products. If the successful trend of the last 13 years under this Conservative Government continues, their profits will be even further reduced.

If we are given full information about the contents of food products, we shall be able to make the right choices as consumers. The right choices will lead to a healthy nation, which we all want to see. The approach adopted in the White Paper will lead to what we want to see.

8.48 pm

Ms. Tessa Jowell (Dulwich)

When I held my weekly surgery last Monday I met a lady whose circumstances were typical of those of many of the people who come to see me every week. She came to my surgery with her husband and three children. Both she and her husband are jobless, poor and living in accommodation that is not big enough for them and their family. Two of their children have asthma. The flat is infested with cockroaches, and that morning she had taken a cockroach out of her baby's mouth as she was eating breakfast.

For my constituents, the debate on "The Health of the Nation" must be measured against the extent to which the quality of their lives and the opportunities for their children will be improved. The solutions to the economic and social difficulties facing so many families I represent are way beyond fine tuning aspects of their life style. Their circumstances demand collective and whole-hearted solutions, which only the Government can deliver. The health of the nation will be measured by its results, not by its fine words.

In my constituency, twice as many babies die within the first year of birth as in Tunbridge Wells, which is about 50 miles down the motorway, and three times as many die as in the Prime Minister's constituency of Huntingdon. The reason why perinatal mortality is much higher in my constituency has nothing to do with the quality of the maternity and ante-natal services that are available. King's College hospital has one of the finest neo-natal units in Europe and obstetric services of which we should be very proud; but so many women who are admitted to King's to be delivered come from homes that are damp, they have had inadequate ante-natal care, they are poor and they have not been able to enjoy a good diet in the months leading up to their baby's birth.

Deprivation and perinatal mortality go hand in hand. Of course we must celebrate the fact that huge strides have been made in reducing the average national rates of perinatal mortality, but the national average obscures wide regional variations, and the rate of perinatal mortality in my constituency is still one of the highest in the country. My constituents also experience the high rates of heart disease, lung cancer and sexually transmitted diseases. All are related to poverty and the physical deprivation of the part of Camberwell that I serve.

It is ironic that one of my constituency's most respected and well-used family health clinics was closed a year ago by the health authority, which was required to make savings in preparation for becoming a trust. Until news of its closure became known locally, the Amott road clinic was well known, accessible and a point of access to family planning, contraceptive advice, well woman services and ante-natal services, which that deprived population of inner London so desperately needed and without which the link between the aspirations of the health of the nation and improvements in the quality of life will never be achieved.

I am pleased to see that attention has been given to the mechanisms by which rhetoric is turned into practical improvements, but we must wait and see whether the device of a Cabinet Committee will be adequate. Some say that housing and income in improving the health of the nation are so important that the lead should lie with the Department of the Environment rather than the Department of Health. Certainly, if the Government do not commit the money to will the ends, this will simply remain a rhetorical exercise, unfulfilled in its promise—certainly to the people I represent.

Like many other hon. Members, I should like to deal briefly with the issue of smoking and the Government's clear responsibility to act in the face of the absolutely unanswerable evidence. It is worth bearing in mind the scale of the smoking epidemic and of the devastation that smoking causes. According to statistical probability, in a roomful of 1,000 smokers, one person will be murdered or will die violently and five or six people will be killed in road traffic accidents, but 300 people will die because of smoking or smoking-related illnesses. The failure to take the most effective possible action in the face of the overwhelming body of medical and scientific evidence is nothing short of negligent.

It is particularly important that we target the need to stop children from smoking. Many of us will have taken part in the launch of the Health Education Authority's profile of smoking throughout the nation—I certainly did. Nine out of 10 young people under the age of 15 have smoked. Smoking is a habit acquired in late childhood, and for two out of three adults becomes established for life. It is very difficult to give up smoking once one has the habit.

It is important that we invest resources in stopping children smoking. I was struck by the remarks of a constituent who told me how his daughter had asked to be taken to buy some sweets "from the smoking shop". The sweetshop's canopy is sponsored by one tobacco firm, and stickers all around the door are sponsored by another. One finds out whether the shop is open or closed by looking at another set of tobacco advertising stickers. A ban on cigarette advertising and tobacco sponsorship of sporting events is undoubtedly one of the most constructive steps that we can take to stop children starting to smoke. For the Government to ban such advertising would probably be the most significant step that they could take towards improving the health of the next generation.

8.58 pm

Ms. Diane Abbott (Hackney, North and Stoke Newington)

In the context of the White Paper I should like to speak about the proposals in the Tomlinson report, which will be published tonight, for the wholesale closure of some of our London hospitals. Of course, the targets in the White Paper are not achievable except within the context of general practitioner care and hospital care.

Early in the debate the Secretary of State implied that the proposed closures would have universal support. She may be in for a surprise. Of course there are historical anomalies in the pattern of health provision in London —generally speaking, we have suffered from low standards of primary and community care—but in truth the proposed closures are the inevitable result of a Government strategy motivated primarily not by the health of the nation but by the need to cap costs.

In the run-up to the general election it was clear that under the new market system introduced by the Government the London teaching hospitals were coming under pressure. Of course, the Government queried not the new market mechanisms but the existence of our teaching hospitals. They were clearly terrified that one of those hospitals would collapse before the election, so they took short-term steps.

There were strong administrative reasons for the Tomlinson report, but I believe that the Government will use it as a device—

Mrs. Virginia Bottomley

The hon. Lady does not yet know what the Tomlinson report will say, but she may have read the King's Fund independent report. Does she feel that her remarks are equally relevant to that report?

Ms. Abbott

I shall come to the King's Fund report later in my speech. If I may be allowed to continue, I was saying that the Government will use the Tomlinson report as an excuse to close hospitals and to present an essentially cost-driven strategy as something else.

We are already hearing—we shall hear a lot more in the coming weeks—about London's "redundant" hospitals, and I want to ask whether those hospitals really are surplus to our current requirement. In so doing, I shall indeed refer to the King's Fund report.

It is easy to look at a computer printout and say that we in London have more hospitals per head than any other part of the country. I suspect that a computer printout may be all that the Secretary of State has looked at. I put it to her—thousands of Londoners will be doing the same over the next three months—that those figures are misleading. In London there is the enduring problem that the population is underestimated, both in censuses and in the electoral registers, due to homelessness, shifting population, refugees, immigrants, and so on. At the general election I found that 2,000 members of my electorate had gone missing. In that there is no substantial loss of population in Hackney; those people are simply not accounted for in the official lists and figures.

The Secretary of State and her colleagues in government have refused to accept—and will continue to do so in the debates on the Tomlinson report—that inner London is different from the rest of the country, different even from other inner city areas. We have more elderly people living alone, more one-parent families, more households lacking basic amenities, huge numbers of commuters—1.3 million of them—and huge numbers of homeless people. It would be more helpful if, instead of using mathematical averages, the Government compared like with like. If we compare inner London with other inner city areas—in Birmingham, Wolverhampton, Liverpool and Manchester—we find that, far from having a superabundance of hospital beds, London has fewer beds than inner city districts in those other provincial centres. As a deprived inner city area, London is less well served than the others.

The Secretary of State referred to the King's Fund report. I shall quote from another King's Fund report: Our results suggest that there are no more beds in London than one would expect, given the nature of London's health districts. I hope that the Secretary of State will quote that in the forthcoming debate on the Tomlinson report, rather than using crude figures for beds per head of population.

In the coming months we shall hear about a declining need for London's hospitals. Let the Government tell that to the nurses at Bart's, with their packed wards, and to the GPs in Hackney who know about the huge waiting lists. Bart's is one of my local hospitals, and it is threatened with closure. The Secretary of State and other Tory politicians will be telling us how such hospitals serve a non-existent or vanishing population. Yet Bart's hospital serves almost 250,000 people within a two-mile radius—if we include commuters that rises to almost 500,000 people—and its 24-hour accident and emergency service is always busy. If our hospitals are so redundant, why are there 150,000 people on the waiting lists in London? The problem with the teaching hospitals is not that they provide too many beds but that there is not enough money to fund Londoners being treated in them.

We shall hear that teaching hospitals are too expensive. Their costs have been inflated because they are forced to include the notional value of their sites, although they were paid for hundreds of years ago. General practitioner fund holders and health fund managers outside London increasingly send their patients to local general hospitals instead of to London teaching hospitals. If consumers are to make an informed choice, the Secretary of State should provide more information.

We do not hear enough about outturn figures in the NHS or about the mortality rates of some of the procedures practised in our teaching hospitals and in hospitals outside London. If we had more outturn figures, and if we knew more about mortality rates, we might find that, although it is cheaper to do some things in our general hospitals, the outturn is not necessarily so good as in some of our top teaching hospitals.

The Minister will tell us about out-dated facilities. At Bart's £66 million has been spent on capital developments in the past five years. We have beautiful new children's wards paid for largely by fund raising. We have some of the most technically advanced operating theatres in Europe. There are valuable specialties at Bart's which will be lost if it is shut. Those specialties include child cancers, respiratory medicine, diabetes and low birth weight research.

There will be an effect on medical training. Bart's has one of the best medical schools in London. In three of the past five years, Bart's students have been top in the final qualifying examinations.

Apart from many misleading ideas about redundant hospitals, empty beds and declining needs, the Secretary of State will tell us about the need to develop primary care and community care in place of hospital care. Let us be realistic. The Secretary of State knows as well as we do that in the context of the current public expenditure round the likelihood of money being available for sufficient primary and community care is nil. If the Secretary of State goes into the three months' consultation on the hospital closures giving airy promises of increased funding of primary care and community care, she will be perpetrating a fraud.

Some have spoken of raising money from the sale of the sites. The Secretary of State must know that many of the big hospital sites in London have been found to be unsaleable.

Bart's is part of a trust with Homerton hospital, which is bang in the middle of my constituency. Despite all its problems, Homerton hospital maintains a high standard of care. If Bart's is shut, the standard of care at Homerton will necessarily drop because Homerton has relied very much on consultants and doctors based at Bart's. Conservative Members shake their heads. I had my baby last year at Homerton hospital. I had the benefit of the care and help of Bart's-based obstetricians, gynaecologists and doctors. Like thousands of ordinary Hackney women and girls, I had access to the finest consultants and doctors one can imagine. If Bart's is shut, Homerton will inevitably decline into a second-rate, inner city hospital.

The employment aspects of shutting our city hospitals are of absolutely no interest to the Secretary of State. Hospitals such as Bart's, St. Thomas's and Guy's employ thousands of local people, especially women. In areas such as Hackney, where industry has gone completely down the drain, the only two major employers left are the local authority and the health authority. The closures suggested by the Tomlinson report will be devastating to the local economy and especially to local women, many of them black or from minority groups.

I have a direct question for the Minister. I am trying to do some research on the contribution that generations of nurses from the Commonwealth have made to the British health service. I wrote to the Minister some months ago asking for help and any information that he had. I know that the Department of Health has information because I spoke to one of its statisticians. I know that it has extensive figures of nurses who came from the Commonwealth in the 1950s and 1960s. I received a letter signed by the Minister saying that he had no information on Commonwealth or black nurses. That is obviously untrue. I will be seeking a meeting with the Minister and I hope that he will be more helpful then. It is an important project. A whole generation of women gave their lives to the health service and I want to document that service.

I seriously ask Conservative Members whether we have learnt the lessons of the 1980s, especially from what happened with the closure of the long-stay mental facilities outside London. When the proposals came forward to close those long-stay medical facilities, we were told the same things that we are being told about the teaching hospitals. We were told that they were old-fashioned facilities, that medical practice had moved on, that those people should be cared for in the community, and that that was the onward march of progress.

I was a Labour councillor on Tory-controlled Westminster city council in the 1980s. We went to the Government and said, "Unless you provide us with the money, there is no possibility of adequate training and care being provided." The Government ignored us. The long-stay hospitals were shut and we see the results of that on our streets every night. Mentally ill and unhappy people are sleeping on the streets because closures were forced through, allegedly for medical and managerial reasons, but in reality to cut costs.

The Secretary of State for Health and Conservative Members may think that the closure of a whole string of London teaching hospitals will be greeted with universal acclaim. I am afraid that they are wrong. My mother and many of my female relatives worked in London hospitals. Like many Londoners, I have a close personal relationship with those hospitals, not just as a customer or patient but in terms of my family and the people I know who have worked in them. We shall not take kindly to the wholesale closure of our hospitals on the basis of misleading arguments about numbers of beds per head of population. We shall not take kindly to the closure of our hospitals on the basis of groundless policies of more money for primary and community care. The proposals in the Tomlinson report for the closure of so many of our teaching hospitals are a disgrace. They do not reflect the reality of health and medical needs in inner London.

In the past 10 days we have seen how much of a battering the reputation of the President of the Board of Trade has taken in respect of his attempts to close 31 pits. That battering will be as nothing to the battering of the reputation of the Secretary of State for Health if she goes ahead with the misbegotten plans to slaughter so many of our great teaching hospitals.

9.11 pm

Mr. Hugh Bayley (York)

After a decade or more of a Government wedded to free market principles, I am delighted to see that Adam Smith and the "Wealth of Nations" is giving way to "The Health of the Nation".

I welcome the emphasis in the White Paper on health rather than health care. The last Labour Government were committed to that emphasis. That was one of the reasons why the Black report—one of the first reports on the health of the nation—was commissioned. It is a great shame that that report was buried more than 10 years ago, to resurface in policy terms only at this late stage. I also welcome the emphasis on health outcomes and not just health processes.

Much reference has been made to tobacco advertising. When the Health Education Authority published its book last week on the smoking epidemic in the United Kingdom, it asked me to help with a local launch. At that launch, York health authority asked me to sign a pledge calling on the Government to ban tobacco advertising. In these days when health authorities are under the rule and diktat of the management executive and of Ministers, I should like an assurance from the Minister that he will not retaliate and victimise York health authority by abolishing it.

There was no mention in the Green Paper of health inequalities. In the last few pages of the White Paper, there is reference to "socio-economic groups." It refers not to health inequalities, but to health variations, and states: The reasons for these variations are by no means fully understood. They are likely to be the result of a complex interplay of genetic, biological, social, environmental, cultural and behavioural factors. And so they may be, but could they not also be a result of poor housing, poverty and unemployment? Why is that not in the White Paper?

The process by which key areas have been selected and reduced to the small number in the White Paper is exceptionally unclear. It is not transparent. During the process from Green Paper to White Paper, some key areas such as diabetes, hospital-acquired infection, breast feeding, food safety, health and environment have been excluded—perhaps for good reasons or perhaps for bad reasons, but there is no clear explanation of those reasons. Before we talk about priorities in selected key areas, we should know what criteria are being used to select them.

Two criteria, in particular, are missing. One is the principle of equity—that health interventions should be based on health needs equally for people with similar health needs. That was spelt out by the Faculty of Public Health Medicine in 1991 as one of the key principles in the World Health Organisation's "health for all" programme, and it should be stated explicitly and form part of the health for all strategy for England.

The second missing criterion is cost effectiveness, which is vital in a health service that is strapped for cash. That it is missing is all the more surprising because on 8 July when the Secretary of State made her statement on the day on which the White Paper was published, in answer to a point that I made she said: By concentrating on prevention … we can achieve health gain cost-effectively … priority will be given to the key areas, chosen because through them we can most effectively improve the health of the nation. Yet cost effectiveness does not appear in the selection process. The costs issue is extremely important. Also on 8 July, I posed a very straight question when I asked: has the Department costed these plans?"—[Official Report, 8 July 1992; Vol. 211, c. 351.] I asked the Secretary of State whether there would be new money to implement them. That question goes to the heart of the issue. If there is no new money, the implementation will either stall or take place only at the expense of cuts in existing health services. The costs are real. During the AIDS campaign, a leaflet was delivered to every door in the country—at a cost, according to the Office of Health Economics, of £20 million. The Centre for Health Economics in my constituency of York and the York Health Economics Consortium estimate that the resources for even a modest—their word—smoking strategy is £20 million to £30 million a year. In its briefing for the debate, the House of Commons Library states: Not all aspects of the strategy have significant financial implications but some do. When we add them all together, the costs will be high—millions for AIDS, millions for smoking, and millions for other priorities in the document. It will cost hundreds of millions altogether. That has to be funded by new money, or serious problems will arise. I ask the Minister to spell out the missing part of the White Paper: what finance will be provided to bring in the new benefits? Will the finance have to come from cuts in other national health services?

9.17 pm

Ms. Dawn Primarolo (Bristol, South)

I congratulate the hon. Member for Falmouth and Camborne (Mr. Coe) on his maiden speech. I too am making my maiden from the Dispatch Box this evening. The Opposition entirely agree with the hon. Gentleman's assertion about the value of a national health service. That assertion is beyond dispute. The hon. Gentleman is right to say that we dispute with the party that he represents how the national health service is financed and run. We agree also that the best way to make sure that the national health service is used properly is to stop people being ill in the first place.

I thank my hon. Friends for their support and their excellent contributions covering the very important issues of health care and the health of the nation.

The debate is held in the shadow of the leaked proposals of the Tomlinson report. Those proposals will butcher the health care services in London. The proposals suggest the closure of St. Bartholomew's, Charing Cross, Queen Charlotte's, the royal ear, nose and throat hospital and the tropical diseases hospital. They propose the merger of St. Thomas's and Guy's and the merger of the Middlesex and University College hospitals, as well as cuts at St. Mary's Paddington and sales of part of its site. They suggest the rationalisation of the Royal Brompton and Marsden hospitals, possibly on the Charing Cross site, with a consultation period—this will comfort them—of three months.

What price the health of Londoners who will be affected by those drastic cuts? The Government have an ideological commitment to the market and an ideological obsession that has failed the economy, jobs and industry. That obsession will destroy our national health service. The market is supposed to find the cheapest, most efficient alternatives for consumers. Are those closures what the market will mean to Londoners? The market will find alternatives that maximise profits and the position of shareholders, then make it acceptable to consumers only because there is no alternative.

The market is fragmenting the national health service. It is encouraging competition, commercialisation and the creeping privatisation of care. The Government are preventing the national health service from co-operating, collaborating, and sharing experiences and expertise for the benefit of those who wish to use the services. Market competition is the priority, and strategic planning goes by the board.

There is much evidence to suggest that the market and the Government reforms are making the national health service more expensive. The Department of Health's figures show a tenfold increase in the cost to the national health service of general managers. Salaries increased from £25 million in 1987 to £250 million last year. The Office of Health Economics' figures show that the number of nurses and midwives per thousand of the population is set to drop to its lowest level for 10 years.

At a recent conference, Mr. Evans, the professor of geriatric medicine at Oxford university, said that one fifth of coronary care units have an upper age limit for admission. To refuse treatment on the ground of age is discrimination. If patients could pay, I am sure that their money would not be refused on the basis of their age.

A hospital described by the Prime Minister as a model of efficiency and consumer service announced ward closures and the cancellation of non-urgent surgery the day after his visit. The 640-bed hospital in Penarth was one of the 36 public service organisations to win the first charter mark award. Hospitals should beware of the charter mark award, as it may herald their closure.

Many targets should be set for improving the health of the nation, but the most important and frequent cause of ill health is poverty and inequality. Florence Nightingale understood the links between poor health and poor housing. In drafting "The Health of the Nation", the Secretary of State has demonstrated that she does not understand the links between ill health and social deprivation. Health should mean a state of complete physical, mental and social well-being, not merely the absence of disease, important though that is. But the policy of "The Health of the Nation" can be summed up in one phrase: the absence of Government where they are needed and the interference of Government where they are not.

The most glaring absence of Government in current health policy stems from the denial of the link between povery and ill health. This Government do not believe in society; they see the country as a multitude of individual consumers. This philosophy translated into the health of the nation means that the point is not to change society where bad health is caused but to influence individuals so that they can choose, if they can afford it, a different life style that will improve their health.

Mr. Trend

It will not have escaped the hon. Lady's attention that Conservatives are fed up with hearing the parrot-like cries of "poverty". That is too simplistic a solution to a complicated problem. I will put to her another proposition that she may find too simplistic, but it is a black and white one.

I recently went to Hong Kong, where the housing is cramped, the working conditions are poor, and the health services less extensive than here; where there is greater pollution and humidity; where the people are overcrowded and suffer all the stress of a metropolitan society—yet infant mortality there is lower than ours and life expectancy higher. How does she explain that?

Ms. Primarolo

Just as the Government cannot produce an expert to prove that coal is more expensive, so they cannot produce an expert who will deny that there is a link between poverty and ill health.

The strategy of the White Paper could almost be said to run as follows. Now that poverty has been abolished—this fits in with what the hon. Member for Windsor and Maidenhead (Mr. Trend) has said—unemployment cannot he helped and housing problems have been solved, health promotion is just a question of good management.

Mildred Blaxter's recent work has demonstrated that people living on low incomes are exposed to multiple deprivations which put their health at risk. I refer to working conditions, diet, accidents, living conditions, environment and smoking, to name but a few. People with higher incomes, she says, are less likely to be exposed to these multiple risks because they are more likely to be able to afford good housing and a decent diet and to be able to live in a nice environment.

The Government's approach—of encouraging good life style practices only—may help the few people who are better off, but those suffering from the deprivations of low income need a great deal more doing for them. The Government need clear evidence, they say, of what causes ill health, but still the Department of Health will not produce figures on the effect of income deprivation and working conditions on health. So the Government deny the link but will not produce the figures.

Dr. Liam Fox

Surely the hon. Lady is not telling us that the huge increase in immunisations since the introduction of the GP contract—an increase in all types of social area—is not to be welcomed?

Ms. Primarolo

The hon. Gentleman will have to wait till I reach the relevant part of my speech.

Just over a decade ago, we had what could be described as a great debate on the nation's health, or at least we attempted to start it. The then Labour Government, so often quoted by the current Government but fast disappearing from the memories of many of us because it was all so long ago, commissioned the Black report on health inequalities. I am sure hon. Members will recall that the Conservative Government hushed up the findings of that report as soon as they possibly could because it revealed the incontrovertible link between poverty and ill health. Sir Douglas Black found that deprivation and inequalities in income, wealth, housing and employment added up to thousands of lost years as a result of avoidable disabilities, chronic sickness and premature death.

Black recommended substantial Government intervention to abolish child poverty, to provide children with free school milk and school meals and to improve the housing stock. Countless studies since Black have reaffirmed the causal link between low income and poor health. If one's income is low, one's children are more likely to be stillborn or to die within the first year of life. Parents of those children are also more likely to die young.

Of the 70 major causes of death in women, 54 are more common in women married to men in social classes 4 and 5. The growth of poverty and poor health among pregnant women is causing more babies to be born under weight and vulnerable to illness and death. Infant and perinatal mortality is rising in a number of regions. The former chief medical officer, Sir Donald Acheson, when announcing his annual report last year, merely summarised the weight of that evidence when he remarked: where people are in a position to exercise greater choice in their housing, environment, employment, leisure activity and consumption generally, this has tended to be beneficial to their health. By contrast, those not able to exercise greater choice because of low income, lack of education or lack of capacity to take the initiative tend to suffer more ill health. In the period since the Black report, no other country has seen income inequalities widen so sharply as the United Kingdom. In 1979 under 6 million people lived on or below the state poverty line. In 1987, the number had doubled to 12.2 million, which is nothing to be proud of. Wage inequality is wider now than it has been for more than 100 years when the figures were first collected. The bottom 10 per cent. of male manual workers earn only 63 per cent. of average pay, compared with 69 per cent. in 1886.

More families are suffering from the privations of unemployment and more are living in temporary lodgings that are unfit for habitation. That has a direct bearing on the immunisation programme, as do the poverty and nutritional surveys, which show that there is a direct link between poverty and poor diet, which leads to a greater likelihood of ill health. Poor families go hungry because they cannot afford food, or they are forced to buy unhealthy food that gives them more calories for their money. As a result, evidence is emerging of an increase in obscenity—I mean obesity.

Mr. Trend

It is an obscenity.

Ms. Primarolo

Yes, the figures are an obscenity, because they prove that low-income children have an increased likelihood of heart disease in their later lives.

Mr. Nigel Evans

Will the hon. Lady give way?

Ms. Primarolo

No, because I must finish by a certain time.

As a result of Government policy, the number of children taking school meals has dropped from 4.9 million to just 2.8 million. One in six secondary school children have no hot evening meal—the majority of those children are from poor backgrounds. Many children go to school without eating breakfast, and the midday meal is the only substantial one of the day for many of them. A whole range of evidence shows the link between poor diet and health problems associated with growth and development, tooth decay, obesity, anaemia, bowel disorders, heart disease and cancer, yet the Government steadfastly refuse to revitalise school meals to improve the nation's health.

The Government acknowledged the importance of housing in the Green Paper, but it does not appear in "The Health of the Nation". Yet, as a direct result of the Government's policies, 11,000 homeless families are living in so-called bed-and-breakfast housing. If one provided suitable family accommodation instead of bed and breakfast, one would tackle head-on a range of health problems which stem directly from that inhuman form of accommodation.

For example, birth weight is the most important determinant of a child's health, yet 25 per cent. of babies born to families in bed-and-breakfast accommodation are of low birth weight. That compares with a 7 per cent. national average. Living in dangerously cramped rooms, often with little or no cooking facilities and no play facilities, for as long as seven years in some cases, bed-and-breakfast children are more prone to sickness and to respiratory illnesses, as well as psychological and emotional health problems.

More generally, as housing repairs dwindle, the lack of local authority funds means that children are living in damp houses and falling victim to the respiratory and bronchial illnesses which go with it. Tuberculosis has increased by 10 per cent. this year.

The Government will not take direct action to alleviate the poverty which causes so much ill health and premature death. They have to get rid of free dental and eye tests. They have increased prescription charges and have used GP contracts to pour health promotion money into better-off areas, instead of dealing with acute health needs. That is not good enough.

The Government have confined themselves to setting targets that their civil servants in Whitehall can measure statistically. As the Government choose the topics for which statistics are developed and collected, it is hardly surprising that the process has enabled them to back winners.

The nation's health is divided by a bankrupt, free-market Government, whose policies beget unemployment, which begets poverty and in turn ill-health, and whose health policy is increasing the same free-market business approach, which gives choice and quality only to those who can afford it and neglects those who cannot. No other area of policy shows more clearly the difference between Labour's philosophy and that of the Government.

Conservative Governments have accelerated the causes of ill health by widening the gulf between rich and poor and ignoring it in "The Health of the Nation". We would put the eradication of health inequalities at the core of our health promotion strategy to create a health policy which would be more than the candy floss described by my hon. Friend the Member for Halifax (Mrs. Mahon), more than merely a series of targets in backing winners, a policy that really tackled ill health—the issue raised by the hon. Member for Falmouth and Camborne. We shall ensure the highest quality of support and treatment, free at the time of need, with the greatest choice and flexibility through the national health service, which has been shown to be the most cost-effective in the world.

The Government choose commercialisation, which inevitably leads to a two-tier system based on ability to pay and the rationing of ever more scarce resources between competing units. "The Health of the Nation" is a missed opportunity. The Government could have tackled the major cause of ill health in our society—the poverty that they have created—and it is a scandal that they have not done so.

9.38 pm

The Minister for Health (Dr. Brian Mawhinney)

I begin by welcoming the hon. Member for Bristol, South (Ms. Primarolo) to her new responsibilities. As she knows, I have had mine for a few months longer than she has had hers. However, we are coming to the Dispatch Boxes as comparative newcomers, at least in our present area of responsibility. Before we have too many more debates I think that we shall have to try to find some common ground of language and understanding on what it is that we are to debate. I shall come to that in a moment.

We have had a good debate. A range of views have been expressed, and for the most part in a constructive way. I hope that that will be part of the continuing debate in the months ahead.

If I had believed everything that the hon. Member for Bristol, South said in the context of the policies of a democratic party offering itself to the electorate, that party would not have stood a chance of getting elected. The fact is that the Conservative party was elected. That happened because our policies bear little relationship to the hon. Lady's remarks.

Some of us have reflected with nostalgia on the absence of the hon. Member for Livingston (Mr. Cook). Earlier, however, he told the country that the general election was to be a referendum on health. That was his view and the view of the Labour party; it was not our view. The people made their views clear on the health care of the country. The hon. Member for Bristol, South reflected her party's pro-referendum policy; unfortunately for her, the world has moved on since then.

I am sorry that the hon. Lady could not bring herself to welcome, for example, the fact that in the past year 7.2 per cent. more patients have been treated in national health service hospitals than during the previous year. That statistic represents tens of thousands of patients who have benefited from health care. I should have thought that the hon. Lady would welcome that, just as she would welcome the fact that 8.2 per cent. more patients have been treated in trust hospitals. Unfortunately, she did not do so. I can understand, however, why she did not.

Mr. Bayley

Will the Minister give way?

Dr. Mawhinney

I should prefer to get started before giving way.

The hon. Member for Bristol, South had to follow the lead of the Opposition spokesman, the hon. Member for Sheffield, Brightside (Mr. Blunkett). I was interested to hear what he had to say. I hope that he will accept it in the spirit in which it is intended if I welcome him to the debate and offer my congratulations to him on assuming his new responsibilities. I must say, however, that he redefined the NHS in terms that I did not begin to recognise. He talked about the responsibilities of virtually every other member of the Cabinet except those of my right hon. Friend the Secretary of State for Health. The nation is spending about £100 million a day in the NHS.

I am sure that my right hon. Friend is flattered that the hon. Gentleman thinks that she should be the Secretary of State for the Environment, for Social Services and for Education as well as for Health. The fact is, however, that the NHS and the responsibilities that my right hon. Friend discharges so effectively and to such good effect are the issues that we are debating. I shall take up the point made by the hon. Members for Brightside and for Bristol, South about inequalities later in my reply.

We shall listen carefully to everything that the hon. Member for Brightside says. We shall sift his remarks for information, truth, helpful suggestions and constructive ideas. I must say, however, that we shall listen to him against the background of Sheffield and the National Union of Public Employees. We shall have to draw some conclusions from that.

I congratulate my hon. Friend the Member for Broxbourne (Mrs. Roe) on becoming the Chairman of the Select Committee on Health. I welcome the considerable significance that she attached, as we do, to the importance of developing healthy alliances. She said that she would welcome an annual report on the progress on "The Health of the Nation". I shall be happy to think about that. I undertake to draw her comments about a maternity report, and especially those about post-natal depression, to the attention of my noble Friend the Under-Secretary of State, who has particular responsibility within the Department for those matters.

I also congratulate my hon. Friend the Member for Falmouth and Camborne (Mr. Coe) on his maiden speech. First, I thank him for paying generous tributes to his predecessors from both sides of the House. He will discover that such generosity of spirit is always appreciated by his colleagues. He spoke movingly of his constituency, and rightly, so. Whatever our differences in the House, all of us have an attachment to our constituencies. That is right and proper, and he reflected that in his speech.

We shall, of course, pay particular attention to what my hon. Friend said about the need for the Health Education Authority and the Sports Council to work more closely together. He might even have been suggesting that they go further than that. He has unparalleled experience, not only from his previous activities, glorious as those were, but from having served on both of those authorities. I shall pay careful attention to what he has said.

I am grateful to the hon. Member for York (Mr. Bayley) for his welcome of outcomes. I hope that he will take the opportunity of having a word with his hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody), who, unfortunately, is not in her place at the moment, because she had her usual rant on the subject and the House will have heard her unwillingness to acknowledge—

Mr. John Evans (St. Helens, North)

The Minister would not have said that if my hon. Friend had been here.

Dr. Mawhinney

Yes, I would.

The House will have heard the hon. Lady's unwillingness to acknowledge the fact that 9 per cent. more of her constituents have been treated in the trusts in Crewe.

Mr. Bayley

If the strategy works and the health of the nation improves, will the Minister be celebrating at the Dispatch Box the fact that fewer people will be going to hospital? The fact that more and more people year after year need hospital treatment reflects, in part at least, the point made by my hon. Friends the Members for Sheffield, Brightside (Mr. Blunkett) and for Bristol, South (Ms. Primarolo) that the more people there are who live in poverty and who eat a bad diet, the more people there will be who need their health to be repaired.

Dr. Mawhinney

I am sorry that the hon. Gentleman felt it necessary to make that contribution. I listened carefully to his original speech and with more appreciation than I did to that.

I understand the concern expressed by the hon. Member for Rochdale (Ms. Lynne) about the community care policy. I hope that she will join others on both sides of the House in helping to ensure, through the closer collaboration of health authorities and local authorities, the private sector and general practitioners, that the community care policy is a success, not for the greater glory of the Government, Members of Parliament or local politicians, but for the benefit of the frail elderly for whom it will be an important initiative.

On a personal level, I agree with the hon. Lady that there is probably still more benefit to be derived from expanding and exploring further complementary medicines.

I agree with my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) and welcome his comments on the new hospital that has just been opened in his constituency. I particularly identified with what he had to say, because the Edith Cavell hospital in Peterborough was promised by the last Labour Government and was killed off when the then Chancellor of the Exchequer had to come back from Heathrow to talk to the International Monetary Fund. That hospital was built under this Administration and in that sense my experience is identical to that of my hon. Friend.

I listened to everything that Opposition Members had to say on the health service against the background of the knowledge that for years my constituents were deprived of the hospital care which they should have had and which they needed because the Labour Government incompetently ran the British economy.

The hon. Member for Barrow and Furness (Mr. Hutton) made an important speech and I hope that he will accept it in the spirit in which it is offered when I say that it was also a moving speech. I take his point about the importance of the home safety committees. He will be interested to know that, as part of the implementation of "The Health of the Nation", we are setting up a task force on accidents. I will ensure that the task force's terms of reference include learning from the experience of home safety committees.

The hon. Gentleman's comments, particularly from his own experience, about the need for bereavement counselling are well taken. It is an element in the health service that has developed over the years and is better than it was, but the hon. Gentleman said that there is room for further improvement—and I would not want this debate to end with the hon. Gentleman thinking that I had not carefully noted that point.

I thank my hon. Friend the Member for Woodspring (Dr. Fox) for his comments. He is able, as a former general practitioner, to help the House understand that the new GP contracts have begun to bring improvements to the standard of GP care throughout the country, though there is more to be done. My hon. Friend was right to emphasise the importance of developing primary care in terms of medical education.

The remarks of the hon. Member for Hackney, North and Stoke Newington (Ms. Abbott)—and I am sorry that she is not in her place—about the Tomlinson report told us more about the hon. Lady than the report. Although she has not read it, she felt free to condemn it. People will draw their own conclusions when Labour Members—and I regret that the hon. Member for Bristol, South fell into the same trap—display such a knee-jerk reaction. They will not read the arguments, reflect on them, or consult but simply leap to conclusions.

We will read the Tomlinson report. We will listen to anything that people have to say about it, consult, and then reach conclusions. We will not behave as Labour politicians behaved this evening, and leap to conclusions that arise from prejudice and lack of knowledge and understanding, and dismiss out of hand the work of people who spent considerable time producing arguments for us all to consider.

As to tobacco, it is important to understand the difference between an end and the means of achieving that end. My hon. Friend the Member for Broxbourne stressed the importance of people being able to make informed choices in the delivery of health care. I very much agree. Right hon. and hon. Members on both sides of the House made the point that when it comes to health, Governments—like everyone else—must rely on persuasion, education and information in convincing people to change their life style and behaviour. My right hon. Friend the Secretary of State made that point strongly at the beginning of the debate, and I make it again equally strongly now.

Mr. Blunkett

Does the Minister agree that the £100 million spent on tobacco advertising not only influences those who already smoke but has a direct impact on the lives and well-being of those who, against their will, are passive smokers? That is a consequence of others being persuaded to buy a product that damages their health. The industry continues to spend a large amount of money inducing smokers to continue damaging their health because that is good for their profits.

Dr. Mawhinney

I believe that smoking damages health, and I imagine that that view is shared in all parts of the House. I believe also that advertising influences behaviour. That is precisely why the Government already have in place restrictions on tobacco advertising.

Like a number of other hon. Members, I have read the advertisement in today's edition of The Independent. It is unquestionably true that the advertisement has been signed by a number of very distinguished people. I am not sure that I recognise every fact on which the argument purports to be based, but the statement is clearly important, and we shall reflect on it after the publication of the Smee report—which, as my right hon. Friend the Secretary of State told the House, will be next week. look forward with interest to hearing what will no doubt prove a lively discussion about it. Incidentally, everything that the hon. Member for Brightside said about the report in his speech was wrong.

I shall be even more impressed if I open tomorrow's edition of The Independent and find another full-page advertisement, signed by all the same people, saying that children both of whose parents smoke have a 15 per cent. likelihood of smoking, that children neither of whose parents smoke have a 6 per cent. likelihood of smoking, and that therefore all those distinguished people want parents to stop smoking so that the prevalence of smoking among children drops by 150 per cent. No one in the House or in the country believes that a ban on advertising would lead to a 150 per cent. reduction in the prevalence of smoking among children; yet that is the statistic given by the OPCS survey.

I look forward to opening Saturday's edition of The Independent and seeing a further advertisement signed by all those distinguished people. I hope that on Saturday they will be saying that a 10 per cent. increase in the price of cigarettes is likely to produce a decrease in smoking prevalence of around 5 per cent., and that they will be encouraging not only the Chancellor of the Exchequer but all our European partners to pay much more attention to price than to some of the other issues that are currently on the agenda.

I look forward to opening The Independent on Monday, and seeing yet another full-page advertisement—by the way, I am not receiving a rake-off from the paper for this commercial—in which the same distinguished people ask whether the country is aware that one of the most important influences on children in regard to smoking is peer pressure. If a child has a boyfriend or girlfriend who smokes, that is one of the best predictors available in all the statistics. Opposition Members run the risk of mixing up the means and the end. We have no difficulty about the end, but a variety of means need to be put in place to achieve that end.

Let me remind the House that, between 1974 and last year, the prevalence of smoking in this country dropped by one third as we pursued a range of policies—none of which, incidentally, included the total ban on advertising that is advocated by Opposition Members. Let me also remind the House what my right hon. Friend said about the position of this country in Europe in terms of smoking reduction. We are determined to use all the means at our disposal to achieve the further reduction specified in "The Health of the Nation".

There is a variety of ways in which the policy will be implemented—not only through the Cabinet Committee to which my right hon. Friend referred, but through working groups, one of which I chair. People from different walks of life are involved. One of the groups will be chaired by the chief medical officer, whose job will be to monitor and review progress towards achieving the targets; another will be chaired by the chief executive of the management executive, and will be designed to carry forward the policy within the NHS.

Task forces will be set up on nutrition, smoking, accidents, the workplace, physical activities and mental illness. All of them, and many others, will combine to carry forward and put into place the first-ever health strategy for the country, a health strategy that depends on all of us playing our part co-operatively, to the benefit of the health of the nation. I look forward to that being achieved in the years to come.

It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.